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Background   AF  ablation ( AFA ) with pulmonary vein isolation ( PVI ) is highly successful for paroxysmal atrial fibrillation ( PAF ). However, success rates for persistent  AF  (Ps AF ) are significantly lower. In this study we evaluate the impact of left atrial ( LA ) low voltage areas ( LVA ) on response to  AFA .    Methods  Consecutive patients undergoing first‐time radiofrequency  AFA  were included (n = 160, 53%  PAF ).  PVI  was performed followed by  LA  voltage mapping during sinus rhythm. Patients were categorized as having  LVA  based on the presence of  LVA  (0.2‐0.5 mV) in the  LA  assessed visually by the operator intra‐procedurally. Further adjunctive  LA  ablation was performed at the operators’ discretion. The end‐point was recurrence of any sustained atrial arrhythmia (atrial fibrillation/tachycardia/flutter) during 12 months follow‐up.    Results  All patients had  PVI  and 23 (14%) had adjunctive  LA  ablation.  LVA  were found in 49 (31%) patients and were an independent predictor of arrhythmia recurrence. Patients with  LVA  compared to those without had significantly lower 12‐month arrhythmia‐free survival in both  PAF  (38% vs 76%;  P  = 0.002) and Ps AF  (27% vs 61%;  P  = 0.015). Ps AF  patients without  LVA  (93% had  PVI  alone) had similar arrhythmia‐free survival to patients with  PAF  (61% vs 67%, respectively;  P  = 0.42). Recurrence in patients with  LVA  compared to those without was more likely to be an organized atrial arrhythmia rather than  AF  (16/30 recurrences vs 2/26,  P  < 0.001).    Conclusions  The presence of  LVA  predicts  AFA  success as well as the type of arrhythmia recurrence. The absence of  LVA  identifies Ps AF  patients that respond well to a  PVI ‐based ablation strategy.

The impact of the presence of left atrial low voltage areas on outcomes from pulmonary vein isolation