Novel ablation approach improves outcomes in patients with persistent atrial fibrillation

Adding digital twin-guided ablation to a standard ablation technique improved outcomes in patients with persistent atrial fibrillation (AF), according to late-breaking research presented in a Hot Line session today at ESC Congress 2025.

One in three adults worldwide will develop AF, a type of arrhythmia characterized by abnormal fast irregular heartbeats. If anti-arrhythmic drugs (AADs) are not successful, a procedure called ablation can be used to destroy tiny sections of heart tissue that may be causing abnormal heartbeats.

Explaining a novel approach to ablation, Principal Investigator, Professor Daehoon Kim from Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea, said: "Ablation using pulmonary vein isolation (PVI) is the standard treatment for AF, but there is considerable scope for improvement, particularly in patients who have persistent AF. We have developed a personalized method that uses digital twin technology to accurately identify specific areas of an individual patient's atrium - called phase singularity (PS) points - that appear to be causing persistent AF in a simulation. In the CUVIA-PRR trial, we investigated whether combining PVI with ablation based on digital-twin guidance is more effective than PVI alone."

This investigator-initiated, randomized superiority trial was conducted at four centres in South Korea. Patients with persistent AF refractory to AADs undergoing first-time AF ablation were included. Patients with paroxysmal AF or permanent AF were excluded. Participants were randomizsed 1:1 to either PVI with digital twin-guided ablation targeting stable PS points or PVI alone. For participants in the digital twin-guided ablation group, maps were generated before starting PVI to identify any stable PS points. AAD use was allowed during a 3-month blanking period after ablation but was discouraged after this. The primary endpoint was any documented atrial arrhythmia lasting ≥30 s after the blanking period, with or without the use of AADs.

A total of 304 participants were randomized and completed the blanking period. Participants had a median age of 61.3 years and 20.7% were women. Stable PS points were identified and ablated in 43.2% of patients assigned to the digital twin-guided ablation group.

At 18 months after ablation, freedom from recurrent atrial arrhythmia was significantly higher in the digital twin-guided ablation group compared with the PVI alone group (77.9% vs. 59.5%; hazard ratio [HR] 0.52; 95% CI 0.33 to 0.82; log-rank p=0.004). Freedom from recurrent atrial arrhythmia without AAD use was more frequent in the digital twin-guided ablation group (45.7%) than in the PVI alone group (31.7%; HR 0.74; 95% CI 0.55 to 0.99). AADs were prescribed after the 3-month period in 51.6% of patients in the digital twin-guided ablation group and 63.8% of patients in the PVI alone group. There were no significant differences in complication rates or total procedure time between the groups. Mean total procedure time (142 vs. 137 minutes) was comparable between the digital twin-guided ablation group and the PVI alone group.

Summarizing the findings, Professor Kim concluded: "Among patients with persistent AF, digital twin-guided ablation plus PVI significantly improved arrhythmia-free survival compared with PVI alone. Previous methods adopting a uniform approach to improve PVI success rates have not been effective and artificial intelligence-guided ablation was found to prolong procedure time. Our tailored, patient-specific ablation approach improved outcomes by precisely targeting the individual mechanisms underlying AF, without compromising safety or extending procedure time."