Detailed characterization of pulmonary vein reconnection and af triggers during redo ablation after single-shot pulsed-field ablation
A Sugino, Y Matsunaga Lee, K Nagai, H Matsubara, T Mukai, N Kobayashi, M Abe, H Nohara, S Kawanami, K Yasumoto, R Muroya, N Okamoto, M Yano, Y Egami, M NishinoAbstract
Background
Pulsed-field ablation (PFA) has become widely adopted for initial pulmonary vein isolation (PVI), and several reports have described findings during redo procedures. However, comprehensive electrophysiological evaluation during redo ablation remains limited, particularly with respect to high-density mapping–based characterization of pulmonary vein (PV) reconnection and induction testing for AF triggers prior to gap ablation. In contrast to the radiofrequency ablation (RFA) era, when wide antral circumferential ablation with a “2-by-2” strategy was standard and segmental isolation was rarely evaluated, lesion characteristics after single-shot PFA may differ substantially. This study aimed to characterize PV reconnection patterns and AF triggers during redo ablation after single-shot PFA.
Methods
Between October 2024 and September 2025, 358 consecutive patients underwent index single-shot PFA for paroxysmal or persistent AF using commercially available systems (FARAPULSE™, PulseSelect™ and VARIPULSE™). During a median follow-up of 177 days (IQR 101–212), recurrence occurred in 41 patients (11%), of whom 17 underwent redo ablation. This study enrolled a total of 13 patients who underwent a redo procedure using high-density electroanatomic mapping (CARTO system). PV reconnection was identified using a multipolar mapping catheter and classified based on 3D geometry as segmental (PV trunk) or antral (atrial side of the antrum).
Results
Among redo patients, 4 underwent FARAPULSE™ and 9 PulseSelect™. PV reconnection was observed in 10 patients (77%). However, segmental PV reconnection was rare (1 patient, 7%). The median reconnection area was 0.8 cm² (IQR 0.05–3.25), predominantly located at the PV antrum. Induction testing prior to ablation was performed in 4 patients (31%). AF was triggered by non-PV foci in 3 patients, all originating from the superior vena cava (SVC) and requiring isolation. In 1 patient, AF was induced from an antral region corresponding to a residual conduction gap.
Conclusion
After single-shot PFA, isolation of individual PVs appears largely durable, whereas limited conduction gaps at the PV antrum were more common. High-density mapping enables precise differentiation between segmental and antral reconnection based on 3D geometry. Additionally, trigger induction test revealed the clinical importance of triggers originating from the SVC and residual PV antral electrograms.Antral PV Reconnection with AF induction