Does mapping matter in pulsed-field ablation? Impact of fluoro-only, HD, and integrated mapping on arrhythmia recurrence and procedural safety

Background

Pulsed field ablation (PFA) with the FARAPULSE system is an established non-thermal strategy for pulmonary vein isolation (PVI) in atrial fibrillation (AF), supported by large registries and randomised trials. Whether integrated electro-anatomical mapping with the FARAVIEW system improves clinical outcomes compared with high-density (HD) mapping or fluoroscopy-only workflows remains uncertain.

Purpose

To compare AF recurrence, pulmonary vein (PV) reconnection and fluoroscopy exposure across three FARAPULSE PFA workflows: HD mapping, fluoroscopy-only, and integrated FARAVIEW.

Methods

We retrospectively analysed 921 consecutive patients undergoing FARAPULSE PFA-guided PVI for AF, assigned chronologically to three groups: HD Map (Group A, n=221), Fluoro-only (Group B, n=638) and FARAVIEW (Group C, n=62). All procedures used standardised PVI lesion sets; FARAVIEW enabled combined real-time mapping and ablation in a single catheter. The primary endpoint was clinical AF recurrence leading to repeat ablation (Re-Do) during follow-up. Secondary endpoints included PV reconnection per initially isolated vein and fluoroscopy time. Differences in categorical outcomes were evaluated using Chi-square tests, with effect sizes quantified as Odds Ratios (OR) and 95% confidence intervals (CI).

Results

Re-Do procedures occurred in 71/221 (32.1%) patients in Group A, 224/638 (35.1%) in Group B and 17/62 (27.4%) in Group C (global p=0.39). Compared with Fluoro-only, the odds of recurrence were numerically lower with FARAVIEW (OR 0.70, 95% CI 0.39–1.25, p=0.23) and HD Map (OR 0.87, 95% CI 0.63–1.21, p=0.42), without statistically significant differences. Figure 1 illustrates the numerical reduction in AF recurrence odds with FARAVIEW compared with Fluoro-only, although confidence intervals cross unity.

Among 3,644 initially isolated PVs, reconnection occurred in 56/884 (6.3%) veins in Group A, 192/2,552 (7.5%) in Group B and 12/208 (5.8%) in Group C (global p=0.36). As shown in Figure 2, clinical recurrence was numerically lowest with FARAVIEW and highest with Fluoro-only, while overall outcomes remained comparable, also FARAVIEW showed the lowest PV reconnection rates.

Compared to Fluoro-only and HD mapping, FARAVIEW significantly minimized median fluoroscopy time (4.6 vs. 10.2 and 8.8 min, respectively; p < 0.001) as well as radiation dose (1222 vs. 2344 and 2043 cGycm²; p = 0.018).

Conclusions

In this single-centre three-phase experience, an integrated FARAVIEW mapping–ablation workflow achieved clinical and PV-level outcomes that were at least comparable (“non-inferior”) to established HD mapping and fluoroscopy-only FARAPULSE PFA workflows, while reducing fluoroscopy exposure. These findings support the use of integrated mapping technology to streamline PFA procedures without compromising efficacy, although larger cohorts are needed to confirm the observed favourable trends.Comparison of Recurrence OddsClinical Recurrence of AF during Follow-up