Individually DEsigned Ablation of Low-voltage areas in patients with persistent Atrial Fibrillation — a randomised controlled multicentre trial

doi:10.1001/jama.2026.17274

IDEAL-AF

Patient / Population Intervention / Exposure Comparison Outcome

In 209 patients with persistent atrial fibrillation and low-voltage areas, pulmonary vein isolation plus individualised low-voltage ablation increased freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation alone.

N

209patients

Design

multicentre (5 Swedish ablation centres), patient-blinded RCT; 1:1 PVI plus low-voltage-zone ablation vs PVI alone; 90-day blanking; 12-month primary endpoint with smartphone ECG monitoring and Holter at 3 and 12 months; 2-year follow-up

Endpoint

freedom from documented atrial arrhythmia (AF or AT) lasting >30 s off antiarrhythmic drugs at 12 months after one to two ablation procedures within 6 months

Relevance

2Important — one of several pillars.

ResultFreedom from documented atrial arrhythmia off antiarrhythmic drugs at one year 67.6% vs 37.4% (OR 3.50, 95% CI 1.98-6.20; P < 0.001). AFEQT quality of life improved as well, with no safety concerns.

Paul Nordin A, Charitakis E, Carnlöf C, et al. Low-Voltage Ablation in Persistent Atrial Fibrillation: The IDEAL-AF Randomized Clinical Trial. JAMA. Published online August 30, 2026. doi:10.1001/jama.2026.17274 10.1001/jama.2026.17274

Discussion & critique

Substrate ablation beyond the pulmonary veins has failed trial after trial when the extra lesions were drawn by rule; here they are drawn by the individual atrium's low-voltage map, and the rhythm result is the largest in this field for years — 68% against 37% off drugs. Two things temper it: 209 patients at five Swedish centres, and an open-label design in which the intervention arm also received more ablation and more time on the table. The quality-of-life gain points the same way as the rhythm, which is not what the sham-controlled trial in this same session found for ablation generally.