{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,9]],"date-time":"2026-11-09T06:24:10Z","timestamp":1794205450442,"version":"4.8.0"},"reference-count":25,"publisher":"American Medical Association (AMA)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA"],"abstract":"\n Importance<\/jats:title>\n Pulmonary vein isolation remains the foundational ablation approach for atrial fibrillation (AF), yet outcomes in persistent AF remain suboptimal. Targeting low-voltage zones identified by electroanatomical mapping offers a promising strategy for enhancing ablation success.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To determine whether adjunctive individualized low-voltage zone ablation improves arrhythmia outcomes and health-related quality of life beyond pulmonary vein isolation alone in patients with persistent AF and significant low-voltage zones.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n \n Multicenter randomized clinical trial with 12 months of follow-up conducted at 5 Swedish ablation centers between May 18, 2020, and April 9, 2026. Of 936 adult patients undergoing first-time ablation and voltage mapping for persistent AF, 209 with low-voltage zones of 3.0 cm\n 2<\/jats:sup>\n or greater were randomized.\n <\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n Following pulmonary vein isolation, patients with significant low-voltage zones were randomized to either receive individualized adjunctive low-voltage zone ablation (n\u2009=\u2009102) or receive no further ablation (n\u2009=\u2009107).<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome was freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months after 1 or 2 ablation procedures within 6 months. Secondary outcomes were time to first recurrence after a single procedure without antiarrhythmic drugs, health-related quality of life, and safety.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Among the 209 randomized patients (median age, 72 years; 109 females [52.2%]), the primary outcome was achieved more frequently in the pulmonary vein isolation plus low-voltage zone ablation group than in the pulmonary vein isolation alone group. Arrhythmia-free survival was achieved in 69 patients (67.6%) vs 40 patients (37.4%), respectively (unadjusted difference, 30.3% [95% CI, 17.4%-43.2%]; odds ratio, 3.5 [95% CI, 2.0-6.2];\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). Time to first recurrence after a single ablation procedure without antiarrhythmic drugs also favored low-voltage zone ablation (hazard ratio, 0.4; 95% CI, 0.3-0.6;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). Improvements in health-related quality of life were greater in the low-voltage zone ablation group, whereas rates of serious adverse events were similar between groups.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Adjunctive low-voltage zone ablation added to pulmonary vein isolation improved rhythm outcomes and health-related quality of life without increasing serious adverse events in patients with persistent AF and significant low-voltage zones. These findings support a low-voltage zone\u2013guided ablation strategy in this population.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n ClinicalTrials.gov Identifier:\n NCT04377594<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jama.2026.17274","type":"journal-article","created":{"date-parts":[[2026,8,30]],"date-time":"2026-08-30T15:30:20Z","timestamp":1788103820000},"source":"Crossref","is-referenced-by-count":5,"title":["Low-Voltage Ablation in Persistent Atrial Fibrillation"],"prefix":"10.1001","author":[{"given":"Astrid","family":"Paul Nordin","sequence":"first","affiliation":[{"name":"Unit of Integrative Cardiovascular, Cancer and Ageing Research (ICCA), Department of Medicine (MedH), Karolinska Institutet, Stockholm, Sweden"},{"name":"Department of Cardiology, Karolinska University Hospital, Stockholm, 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