Win ratio analysis of low-voltage area ablation in persistent atrial fibrillation: sub-analysis of SUPPRESS-AF

Abstract Aims In persistent atrial fibrillation (AF), low-voltage areas (LVAs) in the left atrium are considered arrhythmogenic. Although substrate ablation targeting LVAs may reduce AF recurrence, its effect on broader clinical outcomes remains unclear, and procedural risks must be considered. This study aims to compare hierarchical clinical outcomes between pulmonary vein isolation (PVI) alone and PVI plus LVA ablation in patients with persistent AF and LVAs using a win ratio analysis. Methods and results This was a post hoc sub-analysis of the SUPPRESS-AF trial, including 341 patients with LVAs out of 1364 randomized. Patients received either PVI alone (n = 171) or PVI with LVA ablation (n = 170). Hierarchical outcomes were analysed in order of clinical importance: all-cause death, symptomatic stroke, AF recurrence, bleeding, and periprocedural complications. Win ratio analysis was used for comparison. Baseline characteristics were balanced between groups. The PVI plus LVA group had longer procedure times and higher energy delivery. The win ratio analysis showed no significant difference between groups (win ratio: 1.01, 95% confidence interval: 0.73–1.39, P = 0.940). The PVI-alone group had numerically fewer adverse events, while the LVA ablation group showed a numerical reduction in AF recurrence. Subgroup analyses showed consistent findings. Conclusion In patients with persistent AF and LVAs, LVA ablation added to PVI did not improve hierarchical clinical outcomes and prolonged procedures. Routine use of current LVA ablation strategies is not supported, though targeted substrate modification may warrant further research. Registration UMIN-CTR, https://www.umin.ac.jp/ctry. UMIN000035940.