Impact of substrate modification and shift in recurrence pattern in elderly patients with persistent atrial fibrillation: a sub-analysis of the SUPPRESS-AF trial
T Kanda, H Minamiguchi, Y Okina, T Tsujimura, N Mori, K Nakamoto, Y Ichibori, M Masuda, A Sunaga, N Tanaka, T Watanabe, K Inoue, Y Sotomi, Y Sakata, O IidaAbstract
Background
Pulmonary vein isolation (PVI) is the standard treatment for persistent atrial fibrillation (AF), but its efficacy is limited in patients with advanced atrial remodeling. While the multicenter randomized SUPPRESS-AF trial demonstrated that additional low-voltage-area (LVA) ablation did not significantly reduce 1-year recurrence in the overall cohort, age-related structural changes may influence the therapeutic response to substrate modification.
Purpose
To evaluate the clinical efficacy, safety, and impact on recurrence patterns of additional LVA ablation specifically in elderly patients (≥ 75 years) with persistent AF and identifiable LVAs.
Methods
We conducted a pre-specified sub-analysis of 341 patients from the Full Analysis Set (FAS) of the SUPPRESS-AF trial who had left atrial LVAs (≥ 5 cm2) after PVI. Patients were stratified into elderly (≥ 75 years) and non-elderly (<75 years) groups. The primary endpoint was freedom from AF or atrial tachycardia (AT) recurrence at 1 year without antiarrhythmic drugs. Multivariate Cox proportional hazard analysis was performed for the elderly cohort, adjusting for CHA2DS2-VASc score, body mass index, and left atrial diameter.
Results
In the elderly subgroup (n=176), LVA size was significantly larger compared to the non-elderly cohort (mean 22.2 vs. 16.3 cm2), reflecting advanced remodeling. The PVI+LVA-ABL group demonstrated a significantly higher freedom from recurrence rate compared to the PVI-alone group (72.5% vs. 53.1%; HR 0.55, 95% CI 0.33–0.92, P=0.022). In the multivariate model, additional LVA ablation remained a robust independent predictor of success (adjusted HR 0.52, 95% CI 0.31–0.87, P=0.014). Importantly, substrate modification led to a significant shift in the recurrence pattern; while AF was the dominant recurrence type in the PVI-alone group (38 AF vs. 7 AT), the PVI+LVA-ABL group showed a marked reduction in AF with a relative shift toward organized AT (8 AF vs. 14 AT). Procedure-related serious adverse events did not differ significantly between the groups (1.7% vs. 1.8%, P>0.99).
Conclusions
In elderly patients with persistent AF and demonstrable LVAs, substrate modification is highly effective and safe. LVA ablation not only improves overall rhythm success but also shifts the recurrence pattern from chaotic AF to more organized atrial tachyarrhythmias, suggesting successful homogenization of the arrhythmogenic substrate in the elderly patients.figure