Strategy-Specific Effects of Low-Voltage Area-Targeted Ablation Added to Pulmonary Vein Isolation: A Meta-Analysis of Randomized Controlled Trials.

Background: Left atrial low-voltage areas (LVAs) represent an arrhythmogenic substrate in atrial fibrillation (AF). LVA-targeted ablation is increasingly used as an adjunct to pulmonary vein isolation (PVI), yet outcomes vary across randomized trials, potentially due to differences in ablation strategy. We performed a meta-analysis to evaluate the effectiveness of LVA-targeted ablation added to PVI and to assess whether treatment effects differ between LVA isolation and LVA homogenization strategies. Methods: Following PRISMA, we systematically searched PubMed and CENTRAL for randomized controlled trials (RCTs). Eligible studies enrolled patients with any AF type undergoing voltage mapping and compared PVI plus LVA-targeted ablation (PVI + LVA) with PVI alone. The primary outcome was AF/atrial tachyarrhythmia recurrence during follow-up, as defined in each trial. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Subgroup analyses were performed according to the predominant LVA strategy (isolation vs. homogenization). Results: Six RCTs involving 1565 patients (PVI + LVA, Conclusions: In RCTs of AF ablation, adding LVA-targeted ablation to PVI reduced arrhythmia recurrence. The treatment effect appeared more pronounced with LVA isolation than with homogenization; however, these strategy-specific findings should be considered exploratory and require confirmation in future randomized studies.