ALID score for treatment-effect heterogeneity of adjunctive low-voltage area ablation in persistent atrial fibrillation: A post hoc analysis of SUPPRESS-AF.

Yasuyuki Egami; Haya Matsubara; Ryo Muroya; Kazushi Nagai; Taichi Mukai; Ayako Sugino; Noriyuki Kobayashi; Masaru Abe; Hiroaki Nohara; Shodai Kawanami; Koji Yasumoto; Naotaka Okamoto; Yasuharu Matsunaga-Lee; Masamichi Yano; Masami Nishino; Masaharu Masuda; Nobuaki Tanaka; Tetsuya Watanabe; Hitoshi Minamiguchi; Takafumi Oka; Tomoko Minamisaka; Takashi Kanda; Masato Okada; Masato Kawasaki; Yasuhiro Matsuda; Koji Tanaka; Nobuhiko Makino; Koichi Inoue; Hirota Kida; Tomoharu Dohi; Shungo Hikoso; Akihiro Sunaga; Yohei Sotomi; Yasushi Sakata; OCVC-SUPPRESS-AF Investigators

doi:10.1016/j.ijcard.2026.134674

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ALID score for treatment-effect heterogeneity of adjunctive low-voltage area ablation in persistent atrial fibrillation: A post hoc analysis of SUPPRESS-AF.

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Abstract

BACKGROUND: In persistent atrial fibrillation (AF), the incremental benefit of adjunctive low-voltage area (LVA) ablation beyond pulmonary vein isolation (PVI) remains inconsistent. OBJECTIVE: To examine whether a simple clinical score characterizes treatment-effect heterogeneity of adjunctive LVA ablation among patients with mapped LVA > 5 cm2 and to perform an exploratory supportive analysis in an independent randomized cohort. METHODS: In this post-hoc analysis of SUPPRESS-AF, which included patients with persistent AF and mapped LVA > 5 cm2 after PVI, four variables-age ≥ 75 years, left atrial diameter > 44 mm, estimated glomerular filtration rate < 60 mL/min/1.73 m2, and absence of diabetes-were combined into the ALID score (0-4). Patients were stratified into low (0-1), intermediate (2), and high (3-4) score groups. Because EARNEST-PVI did not use LVA-guided ablation or select patients based on mapped LVA, it was analyzed as an exploratory supportive cohort rather than as an external validation cohort. RESULTS: In SUPPRESS-AF (n = 336), a significant treatment-by-score interaction was observed (P < 0.001). Adjunctive LVA ablation was associated with increased recurrence in the low-score stratum (HR 3.92; 95% CI 1.50-10.20) and reduced recurrence in the high-score stratum (HR 0.48; 95% CI 0.26-0.86). In EARNEST-PVI (n = 494), a qualitatively similar interaction pattern was observed for additional ablation beyond PVI (interaction P = 0.029), although the ablation strategy differed from LVA-guided ablation. CONCLUSIONS: Among patients with persistent AF and mapped LVA >5 cm2, the ALID score identified heterogeneity in response to adjunctive LVA ablation. These hypothesis-generating findings require prospective validation before clinical implementation.

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Humans Atrial Fibrillation Catheter Ablation Female Male Aged Treatment Effect Heterogeneity Treatment Outcome Middle Aged Pulmonary Veins Cohort Studies Atrial fibrillation Catheter ablation Clinical score Low-voltage area Treatment heterogeneity Journal Article Randomized Controlled Trial

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Yasuyuki Egami, Haya Matsubara, Ryo Muroya, Kazushi Nagai, Taichi Mukai, Ayako Sugino, Noriyuki Kobayashi, Masaru Abe, Hiroaki Nohara, Shodai Kawanami, Koji Yasumoto, Naotaka Okamoto, Yasuharu Matsunaga-Lee, Masamichi Yano, Masami Nishino, Masaharu Masuda, Nobuaki Tanaka, Tetsuya Watanabe, Hitoshi Minamiguchi, Takafumi Oka, Tomoko Minamisaka, Takashi Kanda, Masato Okada, Masato Kawasaki, Yasuhiro Matsuda, Koji Tanaka, Nobuhiko Makino, Koichi Inoue, Hirota Kida, Tomoharu Dohi, Shungo Hikoso, Akihiro Sunaga, Yohei Sotomi, Yasushi Sakata, OCVC-SUPPRESS-AF Investigators. 2026-07-16. ALID score for treatment-effect heterogeneity of adjunctive low-voltage area ablation in persistent atrial fibrillation: A post hoc analysis of SUPPRESS-AF.. https://doi.org/10.1016/j.ijcard.2026.134674

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Journal Article; Randomized Controlled Trial resource Aged subject Atrial Fibrillation subject Catheter Ablation subject Cohort Studies subject Female subject Humans subject Journal Article subject Male subject Middle Aged subject Randomized controlled trials study

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