Low-Voltage Area Ablation for Persistent Atrial Fibrillation: The COAST-AF Randomized Clinical Trial.

Adjunctive low-voltage area ablation plus pulmonary vein isolation did not significantly reduce atrial arrhythmia recurrence versus pulmonary vein isolation alone overall (HR 0.82; P=.11) in persistent AF.

• Why it matters: Persistent atrial fibrillation has modest outcomes with pulmonary vein isolation, and low-voltage area ablation has shown promise but needs stronger randomized evidence.
• What they did: In a single-blind randomized trial across 14 Canadian centers, adults with persistent AF >3 months were assigned to PVI plus LVA ablation (n=253) or PVI alone (n=255) and followed 18–36 months; primary outcome was recurrence beyond 90 days after one procedure.
• The result: Overall recurrence was 49.4% vs 57.5% (HR 0.82; 95% CI, 0.65-1.04; P=.11), but in the prespecified LVA subgroup recurrence was lower with PVI plus LVA (49.3% vs 69.2%; HR 0.77; 95% CI, 0.66-0.91; P=.002), with similar safety but longer procedure and ablation delivery times.

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