Prospective Trial of Radiofrequency Catheter Ablation of High Dominant Frequencies After Pulmonary Vein Isolation in Non-Paroxysmal Atrial Fibrillation (PAD-AF Trial): A Multicenter, Randomized Clinical Trial

Background: The role of dominant frequency (DF)–guided ablation after pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF) remains uncertain. We evaluated the clinical and mechanistic impact of DF mapping in a multicenter randomized study. Methods and Results: In this multicenter, prospective study, 103 patients were enrolled. Patients with high-DF sites (≥ 7 Hz) were randomized 1:1 to PVI plus DF ablation (DF group, n = 32) or PVI alone (PVI group, n = 32). Patients without high-DF sites (< 7 Hz, n = 39) underwent PVI only (non-DF group; exploratory cohort). The primary endpoint was freedom from documented AF recurrence without antiarrhythmic drugs (AADs) at 12 months. AF-free survival off AADs was 81.3% in the DF group versus 68.9% in the PVI group (p = 0.228) at 12 months. Arrhythmia-free survival with or without AADs was 78.1% versus 65.6% (p = 0.263). The non-DF group showed the most favorable outcomes (83.3%, p = 0.065 vs PVI group). No adverse events were associated with DF mapping or ablation. Multivariate analysis identified right atrial (RA) low-voltage area extent (HR 1.031, 95% CI 1.005–1.058, p = 0.018) and LA diameter (HR 0.899, 95% CI 0.816–0.991, p = 0.032) as independent predictors of recurrence. Conclusions: In this multicenter randomized trial, adjunctive DF-guided ablation following PVI did not result in a statistically significant improvement in arrhythmia-free survival compared with PVI alone. However, the absence of high-DF sites was associated with favorable outcomes, and RA low-voltage burden emerged as an independent predictor of recurrence, supporting the potential mechanistic value of DF mapping and highlighting the prognostic importance of right atrial structural remodeling. Trial Registration: UMIN000042543.