# Win ratio analysis of low-voltage area ablation in persistent atrial fibrillation: sub-analysis of SUPPRESS-AF **Authors:** Akihiro Sunaga, Yuki Matsuoka, Daisaku Nakatani, Katsuki Okada, Daisuke Sakamoto, Hideaki Hasegawa, Tetsuhisa Kitamura, Masaharu Masuda, Nobuaki Tanaka, Tetsuya Watanabe, Hitoshi Minamiguchi, Yasuyuki Egami, Takafumi Oka, Tomoko Minamisaka, Takashi Kanda, Masato Okada, Masato Kawasaki, Yasuhiro Matsuda, Koji Tanaka, Nobuhiko Makino, Hirota Kida, Shungo Hikoso, Tomoharu Dohi, Koichi Inoue, Yohei Sotomi, Yasushi Sakata, Masaharu Masuda, Masaharu Masuda, Takashi Kanda, Yasuhiro Matsuda, Hiroyuki Uematsu, Toshiaki Mano, Koichi Inoue, Tsuyoshi Mishima, Tatsuhisa Ozaki, Takuya Ohashi, Yasunori Ueda, Tetsuya Watanabe, Yoshio Furukawa, Masato Kawasaki, Mitsutoshi Asai, Takahisa Yamada, Nobuhiko Makino, Hitoshi Minamiguchi, Akio Hirata, Yoshiharu Higuchi, Yasuyuki Egami, Masamichi Yano, Yasuharu Matsunaga-Lee, Masami Nishino, Yasushi Sakata, Shungo Hikoso, Daisaku Nakatani, Hiroya Mizuno, Toshihiro Takeda, Takafumi Oka, Tomoaki Nakano, Kentaro Ozu, Takayuki Sekihara, Katsuki Okada, Tomoharu Dohi, Yohei Sotomi, Akihiro Sunaga, Hirota Kida, Bolrathanak Oeun, Taiki Sato, Yuki Matsuoka, Daisuke Sakamoto, Nobuaki Tanaka, Masato Okada, Koji Tanaka, Yuko Hirao, Katsuomi Iwakura, Tomoko Minamisaka, Shiro Hoshida PMC · DOI: 10.1093/ehjopen/oeag024 · 2026-02-20 ## TL;DR This study found that adding low-voltage area ablation to standard treatment for persistent atrial fibrillation did not improve clinical outcomes and increased procedure time. ## Contribution The study provides new evidence on the clinical effectiveness of low-voltage area ablation in persistent atrial fibrillation using a win ratio analysis. ## Key findings - LVA ablation added to PVI did not improve hierarchical clinical outcomes. - Procedure times were longer in the LVA ablation group. - No significant difference in adverse events or AF recurrence was observed between groups. ## Abstract In persistent atrial fibrillation (AF), low-voltage areas (LVAs) in the left atrium are considered arrhythmogenic. Although substrate ablation targeting LVAs may reduce AF recurrence, its effect on broader clinical outcomes remains unclear, and procedural risks must be considered. This study aims to compare hierarchical clinical outcomes between pulmonary vein isolation (PVI) alone and PVI plus LVA ablation in patients with persistent AF and LVAs using a win ratio analysis. This was a post hoc sub-analysis of the SUPPRESS-AF trial, including 341 patients with LVAs out of 1364 randomized. Patients received either PVI alone (n = 171) or PVI with LVA ablation (n = 170). Hierarchical outcomes were analysed in order of clinical importance: all-cause death, symptomatic stroke, AF recurrence, bleeding, and periprocedural complications. Win ratio analysis was used for comparison. Baseline characteristics were balanced between groups. The PVI plus LVA group had longer procedure times and higher energy delivery. The win ratio analysis showed no significant difference between groups (win ratio: 1.01, 95% confidence interval: 0.73–1.39, P = 0.940). The PVI-alone group had numerically fewer adverse events, while the LVA ablation group showed a numerical reduction in AF recurrence. Subgroup analyses showed consistent findings. In patients with persistent AF and LVAs, LVA ablation added to PVI did not improve hierarchical clinical outcomes and prolonged procedures. Routine use of current LVA ablation strategies is not supported, though targeted substrate modification may warrant further research. UMIN-CTR, https://www.umin.ac.jp/ctry. UMIN000035940. ## Linked entities - **Diseases:** atrial fibrillation (MONDO:0004981) ## Full-text entities - **Genes:** ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) [NCBI Gene 25] {aka ABL, BCR-ABL, CHDSKM, JTK7, bcr/abl, c-ABL} - **Diseases:** left atrial LVAs (MESH:D059446), PVI (MESH:D000071078), LVA (MESH:D009800), thromboembolic (MESH:D013923), heart failure (MESH:D006333), embolic (MESH:D004617), COVID-19 (MESH:D000086382), AF (MESH:D001281), cerebral infarction (MESH:D002544), hypertension (MESH:D006973), AT (MESH:D013617), death (MESH:D003643), Thrombosis (MESH:D013927), atrial flutter (MESH:D001282), cerebrovascular stroke (MESH:D020521), stiff LA) syndrome (MESH:D003310), myocardial injury (MESH:D009202), arrhythmia (MESH:D001145), Bleeding (MESH:D006470), tachycardia (MESH:D013610), diabetes (MESH:D003920), atrial injury (MESH:D014947), inflammation (MESH:D007249) - **Chemicals:** isoproterenol (MESH:D007545), LVA (-) - **Species:** Homo sapiens (human, species) [taxon 9606] ## Figures 3 figures with captions in the complete paper: https://tomesphere.com/paper/PMC12961379/full.md --- Source: https://tomesphere.com/paper/PMC12961379