Low Voltage-Guided Posterior Wall Ablation in Persistent AF: 5-Year Survival Data

A study was conducted to compare long-term arrhythmia free outcomes following posterior wall ablation with either the presence or absence of low-voltage.

The use of voltage-guided ablation (VGA) of the posterior wall (PW) beyond pulmonary vein antral isolation (PVI) in patients with persistent atrial fibrillation (AF) has been shown to significantly improve long-term arrhythmia-free survival compared with nonvoltage-guided ablation. These findings were published in the Journal of Cardiovascular Electrophysiology.

The researchers sought to assess whether the use of PW ablation based on the presence of or absence of low voltage improves long-term arrhythmia-free outcomes. A single-center, retrospective review was conducted.. Researchers presented 5-year data from a clinical study of 2 AF ablation procedures: standard ablation (SA) and VGA. Consecutive patients were included who had presented between 2010 and 2014 for ablation to treat persistent AF. Individuals with long-standing persistent AF, paroxysmal AF, and previous AF ablation were excluded from the study. 

In all of the patients, PVI was performed. With SA, ablation of the left atrial (LA) posterior wall beyond PVI was carried out at the discretion of the operator, not guided by the presence or absence of low voltage. With VGA, additional ablation of the LA posterior wall was carried out only if the voltage mapping of this region while in sinus rhythm demonstrated low voltage.

Five-year follow-up data in a total of 152 consecutive patients were retrospectively reviewed. Participants received 1 of 2 treatments: SA with PVI alone or PVI+PW isolation, according to physician discretion (SA group; n=77) or VGA with PVI and the addition of PW ablation only if low voltage was present on the PW (VGA group; n=75).

LA size and duration of AF were similar in the 2 groups. At the 5-year follow-up, 64% of the patients treated with VGA were atrial tachycardia (AT)/AF-free, compared with 34% in the SA group. Per AT/AF Kaplan-Meier arrhythmia-free survival, those in the VGA arm experienced a significant improvement in AT/AF survival compared with those in the SA arm, which began within the first year and was maintained up to 5 years post-ablation (hazard ratio [HR], 0.358; P <.005).

Although similar AF recurrence was reported in the SA and VGA groups with the use of PW ablation (HR, 0.30 vs 0.27, respectively; P =.96), a significantly higher recurrence of AT was observed in the SA arm compared with the VGA arm (HR, 0.39 vs 0.15, respectively; P =.03).

At the 5-year follow-up, use of VGA was associated with a significant decrease in AF/AT in both patients who received posterior wall ablation (HR, 0.16; P =.002) and those who received PVI alone (HR, 0.33; P =.002), compared with those who received SA PVI alone. Per multivariate analysis, the only procedure-related predictor of arrhythmia-free survival was the use of VGA (HR, 0.30; 95% CI, 0.14-0.64; P =.002).

Limitations of the current study include the fact that although data demonstrate voltage in sinus rhythm is associated with atrial fibrosis, it is also true that voltage changes with activation pattern and length of cycle; the current study focused on voltage measurement during sinus rhythm. Elucidating the mechanistic relationship between voltage and atrial arrhythmias might help to improve understanding of the appropriate target.

“In patients with persistent atrial fibrillation, the use of voltage mapping to guide whether to ablate or not to ablate the posterior wall in addition to PVI improves long-term arrhythmia-free survival when compared to a nonvoltage guided ablation strategy,” the study authors wrote. “A prospective randomized trial is currently underway to study this technique of ablation for persistent atrial fibrillation ([ClinicalTrials.gov identifier:] NCT03355456).”

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Cutler MJ, Sattayaprasert P, Pivato E, Jabri A, AlMahameed ST, Ziv O. Low-voltage-guided ablation of posterior wall improves 5-year arrhythmia-free survival in persistent atrial fibrillation. J Cardiovasc Electrophysiol. Published online March 24, 2022. doi:10.1111/jce.15464