Beyond pulmonary vein isolation: impact of posterior wall and SVC isolation in a zero-fluoroscopy, ICE-guided PFA workflow
G Pontes Saad, J Araujo F Fernandes, G Vignoli Dos Santos, L A Inacio Jr, C Slater, E SaadAbstract
Introduction
Pulsed field ablation (PFA) selectively targets myocardial tissue while sparing adjacent structures such as the esophagus and phrenic nerve, allowing lesion extension beyond the pulmonary veins without increasing the risk of collateral damage. Posterior wall (PW) and superior vena cava (SVC) isolation can be safely incorporated into PFA workflows to improve rhythm outcomes, particularly in patients with persistent atrial fibrillation (AF).
Purpose
To evaluate the safety and clinical impact of extending lesion sets to include PW and/or SVC isolation in a zero-fluoroscopy workflow guided by intracardiac echocardiography (ICE) and electroanatomic mapping.
Methods
Fifty-nine consecutive patients (45 paroxysmal, 14 persistent AF) underwent fluoroless PFA using the Farapulse pentaspline catheter and a 3-D mapping system for navigation and lesion tagging. An ICE catheter positioned in the left atrial cavity enabled direct, real-time visualization of spline–tissue contact. PW isolation was performed in 29 patients (49 %), SVC isolation in 15 (25 %), and both in 4 (7 %). The mean number of PFA applications was 71.8 ± 10.1 (54–92) for PVI-only cases and 90.0 ± 15.3 (64–116) for those with PW ablation. SVC isolation was achieved using the basket configuration at the level of the pulmonary artery on ICE, after electroanatomic mapping of the sinus node activation, ensuring a safe distance, and required 4–8 applications for complete electrical disconnection. Lesion delivery intentionally exceeded the standard 32-application PVI protocol to ensure high-density overlaps. Patients were vigorously hydrated with 2.5-3L of IV saline before lesion deployment. Procedural times, safety outcomes, and arrhythmia recurrences were analyzed.
Results
All procedures achieved acute PVI with complete PW and/or SVC isolation when targeted. Mean procedure time was 78 ± 22 minutes, with no fluoroscopy used. No major complications occurred. One patient had a transient creatinine rise (1.5 - 2.4 mg/dL) that resolved spontaneously. Two early-series cases required remapping to complete isolation, after which the workflow remained consistently successful. During a mean follow-up of 8 ± 3 months, only 2 patients (3 %) experienced atrial arrhythmia recurrence. One of them had undergone PW isolation at the index procedure, and remapping confirmed persistent PV and PW isolation, suggesting a non-PV trigger. Neither esophageal or phrenic nerve injury occurred.
Conclusions
Adding PW and/or SVC ablation to a zero-fluoroscopy, ICE-guided atrial fibrillation PFA workflow enables straightforward isolation of these regions without thermal injury, allowing broader substrate modification while maintaining an excellent safety profile. Extended lesion sets did not increase complications and may enhance rhythm stability.SA Node Map and SVC Isolation Pre & PostICE PW Flower Contact Near Esophagus