Current ablation strategies for persistent AF have shown a limited success rate with frequent arrhythmia recurrences. Recent studies suggest that the atrial arrhythmogenic sites are related to regions with increased fibrosis detected by reduced bipolar voltage area.

Targeting low voltage areas in addition to PVI may represent an efficient strategy for the ablation of persistent AF.

We prospectively included patients with symptomatic persistent AF (mean age: 63±8.8 years, men 69.3%) (Table 1). The ablation strategy consisted in circumferential PVI. Sinus rhythm was restored by electrical cardioversion. A voltage map was performed in sinus rhythm. Complementary ablation was guided by low voltage areas<0.5mV. Success was defined as freedom from AF/atrial flutter or atrial arrhythmia (AT) for a period ranging from 3 months to 18 months or more.

In total, 101 patients with persistent AF were included. Low voltage areas (<0.5mV) were identified in 48 patients (47%). Two or more different sites of LVA were found in 40 patients. The distribution of LVA was (Fig. 1): 32 on anterior wall (30.2%), 25 on septum (23.6%), 8 on posterior (7.5%), 3 on lateral (2.8%), 12 in left appendage (11.3%), 23 on the roofs (21.7%), 3 on inferior (2.8%). RF ablation was performed in all low voltage areas. At the end of procedure, 76 patients (75.2%) were non-inducible. At the end of FU of 18 months, and after a single procedure, 72.3% of patients were free of symptomatic AF (n=73 patients) and 65.3% of patients (n=66) were free of AF/AT recurrence. Atrial tachycardia occurred in 9 patients and re-ablated with success (Table 1, Fig. 1).

These results suggest that PVI with complementary RF ablation guided on low voltage areas may be an efficient strategy for ablation of persistent AF with low incidence of atrial tachycardia during FU.