Atrial remodeling, reflected by left atrial diameter, may influence outcomes of ablation strategies in persistent atrial fibrillation. ESC 2025 sub analysis of the randomized SUPPRESS-AF trial evaluated the efficacy of low-voltage-area ablation (LVA-ABL) in addition to pulmonary vein isolation (PVI), stratified by median left atrial diameter (LAD 44 mm).

Patients were divided into LAD >44 mm and ≤44 mm groups. In patients with LAD >44 mm, those undergoing LVA-ABL had significantly higher recurrence-free rates for atrial fibrillation/atrial tachycardia compared with PVI alone (62.5% vs 43.4%, P=0.016). In contrast, no significant difference was observed in patients with smaller atria (60.8% vs 59.6%, P=0.986). Overall, hazard ratios indicated that the benefit of LVA ablation increases with larger LAD, highlighting left atrial size as a key factor for procedural efficacy.

These findings suggest that patient selection based on atrial remodeling could optimize outcomes of LVA ablation in persistent atrial fibrillation.