Additional anterior flower applications at right pulmonary veins leads to less arrhythmia recurrence

Background

Pulsed field ablation (PFA) is an efficient, safe and effective method to achieve pulmonary vein isolation (PVI) in patients undergoing catheter ablation of atrial fibrillation (AF). However, clinical AF recurrence rates are similar to those after radiofrequency procedures. In recent years, several studies have independently observed pulmonary vein (PV) reconnections at the anterior aspect of the right pulmonary veins (RPVs). Over the past years, workflows have been adapted aiming to reduce PV reconnections, including additional RPV applications.

Methods

We compared outcomes in 246 consecutive patients (Paroxysmal and persistent atrial fibrillation) after PVI using a pentaspline catheter before (NO-Flower, n=123) and after implementation (FLOWER, n=123) of two additional flower applications per vein on the anterior aspect of the right PVs.

Results

Baseline characteristics were comparable, except for female gender (NO-FLOWER: 31%, FLOWER: 20%), CHADS VA (≤2: 67.5% vs. 80.5%) and AF at the beginning of the procedure (36% vs. 22.3%). Type of AF did not differ between the two groups (PAF: 60% vs. 65.5%). Median Follow-up was 441 (365-706) days in the FLOWER-group and 469 (365 – 709) days in the NO-FLOWER-group (p=0.072).

In the multivariate model, adjusting for baseline differences and variables associated with AF recurrence (p < 0.10 in univariate Cox analysis) as well as clinically relevant factors, additional anterior flower applications again showed a protective trend towards a lower risk of arrhythmia recurrence [HR 0.6 (95 % CI 0.34–1.06, p = 0.078)]. Recurrence rates in the FLOWER- versus the NO-FLOWER-group were 18% (n=22/123) versus 40% (n=49/123), [HR 0.475 (95% CI 0.286-0.789; p<0.001)].

When restricting the analysis to patients with paroxysmal AF, additional anterior flower applications were an independent predictor of a significantly lower risk of arrhythmia recurrence [HR 0.42 (95 % CI 0.21–0.85, p = 0.0162)]. Recurrence rates in the FLOWER- versus the NO-FLOWER-group were 15% (n=12/80) versus 35% (n=26/74), [HR 0.414 (95% CI 0.208-0.821; p=0.021)].

Conclusion

Additional anterior flower applications at the RPVs seem to be protective for arrhythmia recurrence after PVI, especially in patients suffering from paroxysmal AF. This workflow should be further evaluated in a randomized controlled trial.Single Procedure Success Rate