Low-Voltage Ablation in Persistent Atrial Fibrillation: The IDEAL-AF Randomized Clinical Trial
Adding patient-specific low-voltage zone ablation improved 12-month rhythm control.
*Multicenter single-blind randomized clinical trial; Level 2 (OCEBM).
Citation
Nordin AP, Charitakis E, Carnlöf C, et al. Low-Voltage Ablation in Persistent Atrial Fibrillation: The IDEAL-AF Randomized Clinical Trial. JAMA. Published August 30, 2026. doi:10.1001/jama.2026.17274
Background
Pulmonary vein isolation is standard ablation for persistent atrial fibrillation, but recurrence remains common. Low-voltage zones on heart mapping may mark scarred atrial tissue that helps sustain abnormal rhythm.
Patients
209 adults with persistent or long-standing persistent atrial fibrillation, first ablation, and low-voltage zones at least 3.0 cm². Key exclusions included left atrial diameter greater than 55 mm, prior atrial fibrillation ablation or left atrial surgery, recent acute coronary syndrome or bypass surgery, reversible atrial fibrillation, and inability to maintain sinus rhythm after isolation.
Intervention
Pulmonary vein isolation plus individualized low-voltage zone ablation.
Control
Pulmonary vein isolation alone, the current standard ablation approach.
Outcome
Primary: freedom from documented atrial arrhythmia without rhythm drugs. Secondary: recurrence after one procedure, rhythm burden, safety, and quality of life using the Atrial Fibrillation Effect on Quality-of-Life score (0-100; higher is better).
Follow-up Period
12 months.
Results
| Outcome | Low-voltage ablation | Isolation alone | Effect |
|---|---|---|---|
| Freedom from atrial arrhythmia at 12 months (primary) | 69/102 (67.6%) | 40/107 (37.4%) | OR 3.5 (95% CI 2.0 to 6.2); NNT 4 |
| Freedom after one ablation, no rhythm drugs | 64/102 (62.7%) | 34/107 (31.8%) | OR 3.6 (95% CI 2.0 to 6.4); NNT 4 |
| Time to first recurrence after one ablation | Favored ablation | Reference | HR 0.4 (95% CI 0.3 to 0.6) |
| Quality-of-life score change | +29.1 median points | +17.6 median points | Greater improvement (CI not reported) |
Results used intention-to-treat analysis. Serious adverse events were similar: 10/102 versus 8/107. The known minimally important quality-of-life difference is 5 points; both groups exceeded it. For the composite rhythm outcome, both atrial fibrillation and atrial flutter or atrial tachycardia recurrences were lower.
Limitations
Operators were not blinded. Low-voltage zones are an indirect marker of atrial scarring. Ablation methods varied by patient, follow-up lacked continuous implanted monitoring, safety power was limited, follow-up was only 12 months, and findings apply to selected first-time radiofrequency ablation patients with persistent atrial fibrillation and significant low-voltage zones.
Funding
Swedish public/nonprofit funders; Coala Solutions AB supplied monitors; industry disclosures.
Clinical Application
For selected persistent atrial fibrillation patients with mapped low-voltage zones, consider adjunctive low-voltage ablation at experienced centers.
Discussion
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In this multicenter single-blind RCT of persistent AF patients with significant low-voltage zones, adjunctive low-voltage zone ablation plus PVI increased 12-month arrhythmia-free survival vs PVI alone (67.6% vs 37.4%; NNT 3.3). Are the validity, safety, and applicability strong enough to change practice? In this RCT, time to first atrial arrhythmia recurrence after a single procedure favored adjunctive low-voltage zone ablation, with a hazard ratio of 0.4. Which interpretation is most appropriate?