Does posterior wall ablation in conjunction with pulmonary vein isolation improve outcomes in patients with persistent atrial fibrillation undergoing pulsed field ablation?
D Musat, A Youssef, L S Park, N S Milstein, A G Bhatt, T C Sichrovsky, M Habibi, S M Kochav, S MittalAbstract
Background
Pulsed field ablation (PFA) is becoming widely used in patients undergoing catheter ablation of atrial fibrillation (AF). Posterior wall (PW) ablation is being added to pulmonary vein isolation (PVI) in patients with persistent AF (PeAF) to improve procedural efficacy, especially since risk of inadvertent damage to the esophagus has been eliminated with use of PFA. There are few studies that objectively assess the impact of this strategy on outcomes.
Objective
To compare the recurrence of AF/atrial flutter (AFL) following PVI PFA alone and PVI with PW ablation PFA in patients with PeAF.
Methods
We enrolled patients with PeAF who underwent ablation using 3 FDA approved PFA systems (PulseSelect, Affera, Medtronic; FaraPulse, Boston Scientific). Recurrences of AF/AFL following a 60-day blanking period were determined.
Results
The cohort included 230 patients (69 ± 10 yrs, 70% male, CHA2 DS2VASc 2.9 ± 1.6) who underwent PVI alone (74 [32%]) or underwent PVI with PW ablation (156 [68%]). Patients ablated with PulseSelect were more likely to have PVI alone, whereas PVI and PW ablation was more common when the FaraPulse system was used (Table). There were no major complications observed. A third of patients had continuous ECG monitoring. During a mean follow-up of 211 ± 120 days, there were similar AF/AFL recurrences in PVI alone and PVI + PW ablation groups, 25 (34%) and 50 (32%) respectively (hazard ratio [HR], 0.88; 95% CI, 0.55-1.41; p=0.607) (Figure).
Conclusions
In this non-randomized cohort of 230 patients with PeAF followed for a mean of 7 months, we observed no difference in recurrence of atrial arrhythmias whether the PW was or was not ablated at the time of PVI. Safety of PW ablation and PVI was similar to PVI only. These data suggest need to better identify the cohort of patients who derive benefit from additional ablation.TableFigure