Low-Voltage Zone Ablation After Pulmonary Vein Isolation Improves Rhythm Outcomes in AF

Adjunctive low-voltage zone (LVZ) ablation on top of pulmonary vein isolation (PVI) improves both rhythm outcomes and quality of life in patients with persistent atrial fibrillation (AF), according to the IDEAL-AF trial.1

These data were presented at the European Society of Cardiology (ESC) Congress 2026 in Munich, Germany, by Astrid Paul-Nordin, MD, PhD, a consultant cardiologist in electrophysiology at the Karolinska University Hospital.1

“If you have a patient with a low-voltage zone, you should ablate it in the first procedure,” Nordin told HCPLive in an exclusive interview. “But I also think that you should choose those patients to go for voltage mapping and point-by-point ablation, and not for a single-shot device at the first procedure.”

Structuring the IDEAL-AF Trial

The Individually Designed Ablation of Low-Voltage Areas in Persistent Atrial Fibrillation (IDEAL-AF) study was a multicenter, single-blind, investigator-initiated, randomized clinical trial, comparing PCI plus LVZ ablation with PVI alone. Patients were eligible for inclusion if they had electrocardiogram-documented persistent or long-standing persistent AF and were scheduled for first-time catheter ablation and met guideline-based indications. Patients were excluded if they had left atrial diameter >55 mm, recent acute coronary syndrome, or congenital heart disease, among other criteria.2

Nordin and colleagues selected a primary outcome of freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months after 1 or 2 ablation procedures within 6 months. Secondary outcomes included time to first recurrence after a single procedure without antiarrhythmic drugs, health-related quality of life, and safety.2

Patients with ≥1 LVZ measuring ≥3.0 cm2 outside of PVI lines were classified as having significant left atrial substrate. Following PVI, these patients were randomly assigned in a 1:1 ratio to receive either individualized adjunctive LVZ ablation or no further ablation. In the PVI plus LVZ ablation arm, ablation was tailored to substrate location via homogenization, box isolation, linear lesions, or any combination thereof. After ablation, burst pacing from the coronary sinus was performed in both groups.2

Patients were then followed up at 3, 6, and 12 months after index ablation. Investigators monitored heart rhythm using handheld single-lead electrocardiogram recordings, which were obtained whenever patients experienced symptoms suggestive of arrhythmia or at the patients’ own discretion. Patients also performed scheduled electrocardiogram recordings twice daily for 14 days before each follow-up visit.2

LVZ Versus PVI

A total of 209 patients were enrolled in the trial, with a median age of 72 years. Among these patients, arrhythmia-free survival occurred in 69 patients (67.6%) in the LVZ arm compared to 40 patients (37.4%) in the PVI-only arm (unadjusted difference, 30.3%; 95% CI, 17.4-43.2%; odds ratio, 3.5; 95% CI, 2-6.2; P <.001). Time to first recurrence after a single ablation procedure without antiarrhythmic drugs also occurred more often in the LVZ arm (HR, 0.4; 95% CI, 0.3-0.6; P <.001).2

Ultimately, Nordin and colleagues concluded that adjunctive LVZ ablation following PVI successfully improved rhythm outcomes and health-related quality of life without increasing serious adverse events in this patient population.1

“Of course, it comes with some negative effects; if you have to ablate more, you will have more fluoroscopy, and more ablation time, and longer procedures,” Nordin said. “But we have such clear results that the patients benefit from it, and we did not see any difference in safety outcomes, so I think it’s a good thing to do the low-voltage zone ablation, even if you have a more complex procedure.”

Editors’ Note: Paul-Nordin reports disclosures with Johnson & Johnson MedTech.

References

1. Paul Nordin A. IDEAL-AF: Individualized Low Voltage Ablation in Persistent AF. Presented at the European Society of Cardiology (ESC) Congress 2026, Munich, Germany. August 28-31, 2026.

2. Paul Nordin A, Charitakis E, Carnlöf C, et al. Low-Voltage Ablation in Persistent Atrial Fibrillation: The IDEAL-AF Randomized Clinical Trial. JAMA. Published online August 30, 2026. Accessed September 17, 2026. doi:10.1001/jama.2026.17274