{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T17:44:07Z","timestamp":1788457447223,"version":"build-2803163510"},"reference-count":29,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"11","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["JAHA"],"published-print":{"date-parts":[[2026,6,2]]},"abstract":"<jats:sec xml:lang=\"en\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p xml:lang=\"en\">Larger low\u2010voltage areas (LVAs) in the left atrium are associated with increased arrhythmia recurrence after atrial fibrillation (AF) ablation. The benefit of adjunctive LVA ablation may therefore depend on substrate extent. This study examined the efficacy of LVA ablation across a spectrum of LVA sizes in persistent AF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      The SUPPRESS\u2010AF (Efficacy and Safety of Left Atrial Low\u2010Voltage Area Guided Ablation for Recurrence Prevention Compared to Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation) trial screened 1364 patients undergoing initial ablation for persistent AF, of whom 342 with left atrial LVAs (\u22655\u2009cm\n                      <jats:sup>2<\/jats:sup>\n                      ) were randomized to pulmonary vein isolation with or without adjunctive LVA ablation. In the 341 analyzed patients, LVA size was categorized as small (&lt;10\u2009cm\n                      <jats:sup>2<\/jats:sup>\n                      , n=106), moderate (\u226510 to &lt;20\u2009cm\n                      <jats:sup>2<\/jats:sup>\n                      , n=127), or extensive (\u226520\u2009cm\n                      <jats:sup>2<\/jats:sup>\n                      , n=108). The primary end point was recurrence of AF or atrial tachycardia within 1\u2009year without antiarrhythmic drugs. Treatment effects across LVA sizes were evaluated using a Cox model with restricted cubic splines.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      AF\/atrial tachycardia recurrence rates were similar between the pulmonary vein isolation+LVA ablation and pulmonary vein isolation\u2010alone groups in patients with small (38.5% versus 29.6%;\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.28) and moderate LVA sizes (40.6% versus 53.5%;\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.15). However, adjunctive LVA ablation significantly reduced recurrence in patients with extensive LVAs (34.7% versus 57.6%;\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.029; interaction\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.054), driven mainly by lower AF recurrence (18.4% versus 42.4%,\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.008). Spline analysis indicated a greater treatment benefit with increasing LVA size, reaching significance around 20\u2009cm\n                      <jats:sup>2<\/jats:sup>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p xml:lang=\"en\">The efficacy of adjunctive LVA ablation increased with substrate size, with a significant benefit observed in patients with extensive LVAs. These findings support a substrate size\u2013guided ablation strategy to optimize rhythm outcomes in persistent AF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Registration<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      URL:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/www.umin.ac.jp\/ctr\">https:\/\/www.umin.ac.jp\/ctr<\/jats:ext-link>\n                      ; Identifier: UMIN000035940.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/jaha.125.047814","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T10:45:51Z","timestamp":1779705951000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Efficacy of Low\u2010Voltage Area Ablation Across Substrate Size in Persistent Atrial Fibrillation: A Post Hoc Analysis of the SUPPRESS\u2010AF Randomized Trial"],"prefix":"10.1161","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3190-7313","authenticated-orcid":false,"given":"Masato","family":"Okada","sequence":"first","affiliation":[{"name":"Sakurabashi Watanabe Advanced Healthcare Hospital","place":["Osaka, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7272-5266","authenticated-orcid":false,"given":"Daisuke","family":"Sakamoto","sequence":"additional","affiliation":[{"name":"Osaka University Graduate School of Medicine","place":["Suita, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5566-466X","authenticated-orcid":false,"given":"Masaharu","family":"Masuda","sequence":"additional","affiliation":[{"name":"Kansai Rosai Hospital","place":["Amagasaki, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8324-1728","authenticated-orcid":false,"given":"Nobuaki","family":"Tanaka","sequence":"additional","affiliation":[{"name":"Sakurabashi Watanabe Advanced Healthcare Hospital","place":["Osaka, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3979-527X","authenticated-orcid":false,"given":"Tetsuya","family":"Watanabe","sequence":"additional","affiliation":[{"name":"Osaka General Medical Center","place":["Osaka, Japan"]},{"name":"Yao Municipal Hospital","place":["Yao, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-0431-4140","authenticated-orcid":false,"given":"Hitoshi","family":"Minamiguchi","sequence":"additional","affiliation":[{"name":"Osaka Keisatsu Hospital","place":["Osaka, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9728-6524","authenticated-orcid":false,"given":"Yasuyuki","family":"Egami","sequence":"additional","affiliation":[{"name":"Osaka Rosai Hospital","place":["Sakai, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3237-3293","authenticated-orcid":false,"given":"Takafumi","family":"Oka","sequence":"additional","affiliation":[{"name":"Osaka University Graduate School of Medicine","place":["Suita, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tomoko","family":"Minamisaka","sequence":"additional","affiliation":[{"name":"Yao Municipal Hospital","place":["Yao, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0200-7196","authenticated-orcid":false,"given":"Masato","family":"Kawasaki","sequence":"additional","affiliation":[{"name":"Osaka General Medical 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