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Randomized Controlled Trial
. 2025 Sep 1;27(9):euaf205.
doi: 10.1093/europace/euaf205.

Impact of renal function on the efficacy of low-voltage area ablation after pulmonary vein isolation: a sub-analysis of the SUPPRESS-AF trial

Yasuhiro Matsuda  1 , Masaharu Masuda  1 , Toshiaki Mano  1 , Takuya Tsujimura  1 , Hiroyuki Uematsu  1 , Hirotaka Ooka  1 , Satoshi Kudo  1 , Mizuki Ochi  1 , Shin Okamoto  1 , Takayuki Ishihara  1 , Kiyonori Nanto  1 , Yosuke Hata  1 , Sho Nakao  1 , Masaya Kusuda  1 , Wataru Ariyasu  1 , Akihiro Sunaga  2 , Nobuaki Tanaka  3 , Tetsuya Watanabe  4   5 , Hitoshi Minamiguchi  6 , Yasuyuki Egami  7 , Takafumi Oka  2 , Tomoko Minamisaka  5 , Takashi Kanda  1   6 , Masato Okada  3 , Masato Kawasaki  4 , Koji Tanaka  3 , Nobuhiko Makino  6 , Hirota Kida  2 , Shungo Hikoso  2   8 , Tomoharu Dohi  2 , Koichi Inoue  9 , Yohei Sotomi  2 , Yasushi Sakata  2 ; Osaka Cardiovascular Conference (OCVC)-Arrhythmia Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Impact of renal function on the efficacy of low-voltage area ablation after pulmonary vein isolation: a sub-analysis of the SUPPRESS-AF trial

Yasuhiro Matsuda et al. Europace. .

Abstract

Aims: The SUPPRESS-AF trial showed that pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation may reduce atrial fibrillation (AF) recurrence in some subgroups. Renal dysfunction is a cause of LVAs due to atrial cardiomyopathy and is also a risk factor for AF recurrence after catheter ablation. The aim of this study was to investigate the efficacy of LVA ablation after PVI stratified by renal function.

Methods and results: This study was a sub-analysis of the SUPPRESS-AF trial, a multicentre, prospective, randomized, open-label trial. A total of 341 consecutive patients who underwent initial radiofrequency catheter ablation for persistent AF and whose LVAs were ≥5 cm2 were analysed. Patients were randomized to PVI alone (PVI-alone group) or LVA ablation after PVI [PVI + LVA-ablation (ABL) group]. Primary outcome was defined as the recurrence of atrial tachyarrhythmias during the 12 months following ablation. Estimated glomerular filtration rate (eGFR) was assessed before ablation, and patients were stratified by chronic kidney disease (CKD) stage. The mean eGFR was 60 ± 16 mL/min/1.73 m2, and 146 (43%) patients developed the primary outcome. In patients with CKD G1-2 (eGFR ≥ 60 mL/min/1.73 m2), freedom from the primary outcome was similar between the PVI + LVA-ABL and PVI-alone groups (53.1% vs. 55.3%, P = 0.59). In contrast, in patients with CKD G3a-5 (eGFR < 60 mL/min/1.73 m2), freedom from the primary outcome was significantly higher in the PVI + LVA-ABL group than in the PVI-alone group (69.1% vs. 43.3%; P = 0.004).

Conclusion: In patients with renal dysfunction, LVA ablation after PVI reduced AF recurrence after radiofrequency catheter ablation for persistent AF.

Keywords: Atrial fibrillation; Catheter ablation; Chronic kidney disease; Left atrial remodelling; Renal function.

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Conflict of interest statement

Conflict of interest: Y.M. has received a grant from the Japanese Heart Rhythm Society, Abbott, and Nihon Kohden outside the submitted work; M.M. has received personal fees from Daiichi Sankyo, Medtronic, Johnson & Johnson, and Boston Scientific outside the submitted work; T.I. has received honoraria from Nipro and Kaneka Medics outside the submitted work; N.T. has received personal fees from Daiichi Sankyo, Bayer, Boehringer Ingelheim Japan, AstraZeneca, Johnson & Johnson K.K., and Medtronic outside the submitted work; H.M. has received personal fees from Medtronic, Abbott, Nihon Kohden, Biotronik, Japan Lifeline, Boston Scientific, Philips, Cook Medical, Bayer, Daiichi Sankyo, Johnson & Johnson, and Microport outside the submitted work; Y.E. has received personal fees from Abbott, Johnson & Johnson, Japan Lifeline, and Medtronic outside the submitted work; T.O. has received personal fees from Beyer and Medtronic outside the submitted work; T.K. has received personal fees from Boehringer Ingelheim, Bayer, Bristol-Myers Squibb, Daiichi Sankyo, Nihon Kohden, Abbott, Medtronic, and Otsuka Pharmaceutical, outside the submitted work; M.Ka. has received personal fees from Medtronic, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Bristol-Myers Squibb, and Abbott outside the submitted work; N.M. has received personal fees from Biosense Webster, Abbott, Medtronic, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer, Daiichi Sankyo, and Otsuka Pharmaceutical outside the submitted work; S.H. has received grants from Medtronic, Johnson & Johnson, and Abbott during the conduct of the study, personal fees from Bayer, Daiichi Sankyo, Medtronic, Boehringer Ingelheim, Johnson & Johnson, Roche Diagnostics, FUJIFILM Toyama Chemical, and Actelion; and non-financial support from Actelion outside the submitted work; T.D. has received grants from Medtronic, Johnson & Johnson, and Abbott during the conduct of the study; K.I. has received personal fee from Daiichi Sankyo, Johnson & Johnson, Boston Scientific, and Medtronic outside the submitted work; Y.So. has received grants from Abbott Medical Japan, Abiomed, Biosense Webster, Boston Scientific Japan, Bristol-Myers Squibb, FUJIFILM Toyama Chemical, Roche Diagnostics, Terumo, TOA EIYO, and Nipro and personal fees from Abbott Medical Japan, Amgen Astellas BioPharma, Bristol-Myers Squibb, and Shockwave outside the submitted work; Y.Sa. has received grants from Medtronic, Johnson & Johnson, and Abbott during the conduct of the study and personal fees from Abbott, Sanofi, Johnson & Johnson, Daiichi Sankyo, Terumo, Medtronic, Bayer, Biotronik, Bristol-Myers Squibb, Boehringer Ingelheim, and Boston Scientific outside the submitted work. T.Ma., T.T., H.U., H.O., S.K., M.Oc., S.O., K.N., Y.H., S.N., M.Ku., W.A., A.S., T.W., T.Mi., M.Ok., K.T., and H.K. have no conflicts of interest to declare.

Figures

Graphical Abstract
Graphical Abstract
A total of 342 consecutive patients were prospectively enrolled in the SUPPRESS-AF study. Patients were initially randomized to pulmonary vein isolation (PVI) alone or PVI + low-voltage area (LVA)-ablation (ABL). One patient was excluded due to missing eGFR data. Finally, 171 patients in the PVI-alone group and 170 patients in the PVI + LVA-ABL group were analysed in this study. In patients with chronic kidney disease (CKD) G1-2, there was no significant difference in freedom from the primary outcome between the PVI-alone and PVI + LVA-ABL groups. Conversely, in patients with CKD G3a-5, freedom from the primary outcome was significantly higher in the PVI + LVA-ABL group than in the PVI-alone group. LVAs, low-voltage areas; PVI, pulmonary vein isolation; RFCA, radiofrequency catheter ablation; AF, atrial fibrillation; ABL, ablation; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.
Figure 1
Figure 1
Patient flow chart. A total of 342 consecutive patients were prospectively enrolled in the SUPPRESS-AF study. Patients were initially randomized to PVI alone or PVI + LVA-ABL. One patient was excluded due to missing eGFR data. Finally, 171 patients in the PVI-alone group and 170 patients in the PVI + LVA-ABL group were analysed. AF, atrial fibrillation; LVAs, low-voltage areas; PVI, pulmonary vein isolation; ABL, ablation; eGFR, estimated glomerular filtration rate.
Figure 2
Figure 2
Association between the primary outcome and renal function. (A) There was no difference in freedom from the primary outcome between patients with CKD G1-2 and those with CKD G3a-5. (B) There was no difference in freedom from the primary outcome between patients by stage of CKD. CKD, chronic kidney disease.
Figure 3
Figure 3
Association between the primary outcome and ablation strategy by CKD G1-2 vs. CKD G3a-5. (A) In patients with CKD G1-2, there was no significant difference in freedom from the primary outcome between the PVI-alone and PVI + LVA-ABL groups. (B) In patients with CKD G3a-5, freedom from the primary outcome was significantly higher in the PVI + LVA-ABL group than in the PVI-alone group. eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; PVI, pulmonary vein isolation; LVA, low-voltage area; ABL, ablation.
Figure 4
Figure 4
Subgroup analysis of the primary endpoint in patients with CKD G1-2 (eGFR ≥ 60 mL/min/1.73 m2). In patients with CKD G1-2, no subgroup in the PVI + LVA-ABL group showed a reduction in primary endpoint compared to the PVI-alone group. CKD, chronic kidney disease; PVI, pulmonary vein isolation; LVA, low-voltage area; ABL, ablation; NYHA, New York Heart Association; LAD, left atrial diameter; eGFR, estimated glomerular filtration rate.
Figure 5
Figure 5
Subgroup analysis of the primary endpoint in patients with CKD G3a-5 (eGFR < 60 mL/min/1.73 m2). In patients with CKD G3a-5, prevention of the primary endpoint was greater in the PVI + LVA-ABL group compared to the PVI-alone group in patients aged ≥75 years and those with CHA2DS2-VA score ≥ 4, NYHA Class I, LAD < 45 mm, without diabetes mellitus, and with LVA ≥ 20 cm2. CKD, chronic kidney disease; PVI, pulmonary vein isolation; LVA, low-voltage area; ABL, ablation; NYHA, New York Heart Association; LAD, left atrial diameter; eGFR, estimated glomerular filtration rate.
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