ALDAS score for low-voltage area burden identifies differential benefit of low-voltage-guided ablation in persistent atrial fibrillation: insights from the SUPPRESS-AF trial
A Sunaga, D Nakatani, K Okada, H Kida, Y Matsuoka, D Sakamoto, H Hasegawa, T Kitamura, M Masuda, N Tanaka, T Watanabe, K Inoue, Y Sotomi, Y SakataAbstract
Background
Low-voltage area (LVA) in atrial fibrillation (AF) reflects arrhythmogenic substrate and may affect outcomes after ablation. However, LVA quantification requires electroanatomical mapping and may not be comparable across catheters and 3D systems. We developed a simple clinical score to estimate LVA burden and tested whether treatment effects differ by score-estimated substrate burden.
Methods
This post-hoc subanalysis used the SUPPRESS-AF randomized trial (persistent AF, first ablation, LVA ≥5 cm²) comparing PVI alone versus PVI plus LVA ablation. Continuous LVA was modeled by gamma regression with a log link, and an additive score was derived from prespecified cutoffs of age, left atrial diameter (LAD), AF duration, hemoglobin (Hb), and history of stroke/TIA/systemic embolism. Patients were dichotomized into low vs high score (≤5 vs ≥6). AF recurrence was assessed by Kaplan–Meier curves and log-rank tests to evaluate effect modification.
Results
Regression coefficients were converted into integer points to construct the ALDAS score: age <70=0, ≥70=+2; LAD <35=0, 35–40=+1, ≥40=+4; AF duration <4=0, 4–10=+1, ≥10=+5; Hb <12=+4, 12–14=+1, ≥14=0; stroke/TIA/systemic embolism history yes=+2, no=0. (Figure) Higher scores were associated with larger observed LVA (Figure). In the low-score group (≤5, n=111), recurrence was 35.1% with PVI alone and 42.6% with PVI+LVA (p=0.417). In the high-score group (≥6, n=226), recurrence was 54.0% and 36.3%, respectively (p=0.0075). The logistic interaction term was significant (p=0.0286). Kaplan–Meier curves showed no separation in ≤5 (log-rank p=0.547) but significant separation in ≥6 (log-rank p=0.0177) (Figure).
Conclusion
The ALDAS score, based on age, LAD, AF duration, Hb, and stroke/TIA/systemic embolism history, provides a practical estimate of LVA burden and identifies patients in whom PVI plus LVA ablation may reduce AF recurrence compared with PVI alone. External validation is warranted.Graphical abstract