Adding digital twin-guided ablation to a standard ablation technique can improve outcomes in patients with persistent atrial fibrillation (AF), according to late-breaking research presented at the 2025 European Society of Cardiology (ESC) congress (29 August–1 September, Madrid, Spain).
“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,” explained principal investigator Daehoon Kim (Severance Cardiovascular Hospital/Yonsei University College of Medicine, Seoul, South Korea). “We have developed a personalised 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, randomised superiority trial was conducted at four centres in South Korea. Patients with persistent AF refractory to anti-arrhythmic drugs (AADs) undergoing first-time AF ablation were included. Patients with paroxysmal AF or permanent AF were excluded.
Participants were randomised 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 three-month blanking period after ablation but was discouraged after this. The primary endpoint was any documented atrial arrhythmia lasting ≥30 seconds after the blanking period, with or without the use of AADs.
A total of 304 participants were randomised 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 post-ablation, freedom from recurrent atrial arrhythmia was significantly higher in the digital twin-guided ablation group compared with the PVI-only group (77.9% vs 59.5%, respectively; hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.33–0.82; 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-only group (31.7%; HR, 0.74; 95% CI, 0.55–0.99).
AADs were prescribed after the three-month period in 51.6% of patients in the digital twin-guided ablation group and 63.8% of patients in the PVI-only group. There were no significant differences in complication rates or total procedure time between the groups—with the mean total procedure time appearing comparable between the digital twin-guided ablation group (142 minutes) and the PVI-only group (137 minutes).
“Among patients with persistent AF, digital twin-guided ablation plus PVI significantly improved arrhythmia-free survival compared with PVI alone,” Kim concluded. “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.”
