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Targeted ablation guided by voltage mapping improved rhythm outcomes in individuals with recurrent atrial fibrillation after initial isolation.  

Researchers conducted a study published in June 2025 issue of Clinical Research in Cardiology to evaluate the effectiveness of repeat atrial fibrillation (AF) ablation combining pulmonary vein isolation (PVI) with substrate-based left atrial ablation targeting low voltage areas (LVA).  

They included individuals with recurrent AF who previously underwent only PVI. Voltage mapping was performed during sinus rhythm. Repeat PVI was done if pulmonary vein (PV) reconnection was identified. Substrate modification was applied only when LVA, defined as electrogram amplitudes < 0.5 mV, were detected using linear or box lesion strategies. Arrhythmia monitoring was carried out for 6 months via a photoplethysmography-based smartphone application.  

The results showed that 58 individuals (37.9% female, median age 66.0 years [IQR 59.8–72.3]) were analyzed. The PV reconnection was detected in 49 individuals (84.5%) and LVAs were present in 31 individuals (53.4%). Ablation included anterior box lesions in 39.7%, anterior linear lesions in 8.6%, posterior box lesions in 17.2%, roof lines in 34.5%, and posterior mitral isthmus lines in 5.2%. Those with LVA were more often female (54.8% vs 18.5%; P= 0.0045), older (71.0 years [IQR 66.0–78.0] vs 62.0 years [IQR 55.0–66.0]; P< 0.0001), and had higher left atrial volume index (50.0 ml/m² [IQR 40.0–61.0] vs 34.0 ml/m² [IQR 28.0–48.0]; P= 0.0014). Arrhythmia-free survival was 66.7% without LVA and 48.4% with LVA (HR 0.6063; 95% CI: 0.2767–1.329; P= 0.2206).  

Investigators concluded that PV reconnection and LVAs were key findings in repeat AF ablation, and combining repeat PVI with individualized ablation targeting LVAs proved effective and safe. 

Source: link.springer.com/article/10.1007/s00392-025-02695-4