Distinct post–pulmonary vein isolation inducibility phenotypes after pulsed-field versus thermal ablation and association with 90-day recurrence
Y Hasegawa, H Furuse, A Kato, M Sakurazawa, N Suzuki, Y Sakaguchi, Y Ikami, S Otsuki, M Chinushi, T InomataAbstract
Introduction
While post–pulmonary vein isolation (PVI) inducibility and its prognostic implications are well established after PVI using thermal ablation, post-PVI inducibility after pulsed-field ablation (PFA)–based PVI remains poorly characterized, and its relevance for short-term recurrence remains unclear.
Objective
To compare post PVI atrial tachyarrhythmia inducibility phenotypes after PFA versus thermal ablation and to explore their association with 90-day early recurrence.
Methods
We prospectively studied 390 consecutive patients undergoing first-time PVI for atrial fibrillation (AF) (PFA, n=177; thermal ablation, n=213). A standardized post-PVI provocation protocol (isoproterenol and burst pacing) was performed in all patients. Post-PVI inducibility was classified as (1) APC-initiated AF (non-PV trigger), (2) inducible mappable atrial tachycardia/atrial flutter (AT/AFL), or (3) AF during burst pacing. The origin of inducible mappable AT/AFL was categorized by activation mapping (right atrium, septal, left atrium, or multiple origins). Induced arrhythmias were managed at operator discretion. We assessed the association between post-PVI inducibility phenotypes and recurrence within 90 days, defined as documented AF/AT/AFL.
Results
Overall inducibility (any inducible AF/AT/AFL) was higher with PFA than with thermal ablation (29.9% vs 20.2%; p=0.033), driven by higher rates of inducible mappable AT/AFL (14.7% vs 6.6%; p=0.011) and AF during burst pacing (10.7% vs 4.7%; p=0.032). Among inducible mappable AT/AFL, left-atrial origin was more frequent with PFA than with thermal ablation (10.2% vs 3.3%; p=0.007), whereas non–left-atrial origins were comparable between groups. In the PFA cohort, 90-day recurrence data were available in 164/177 (92.7%), and recurrence within 90 days differed by inducibility phenotype: 14.9% (17/114) in non-inducible, 0% (0/8) in APC-initiated AF, 47.8% (11/23) in inducible mappable AT/AFL, and 15.8% (3/19) in AF during burst pacing.
Conclusion
Compared with thermal ablation, PFA-based PVI resulted in a distinct post-PVI inducibility pattern, with more frequent inducible mappable AT/AFL (often of left-atrial origin) and AF during burst pacing. In the PFA cohort, recurrence within 90 days varied by inducibility phenotype and was highest in patients with inducible mappable AT/AFL, highlighting the short-term clinical relevance of post-PVI provocation findings after PFA-based PVI.Figure 1Figure 2