Lesion durability after pulmonary vein isolation and linear lesions in complex atrial tachycardias at repeat ablations following focal pulsed field ablation
M Ruwald, C Alhede, X Chen, U Gang, J Hansen, M Haugdal, A Johannessen, C Jons, P K Jacobsen, M Lock Hansen, N Sandgaard, R WorckAbstract
Background
Focal pulsed field ablation (FPFA) has emerged as a promising modality for atrial lesion creation, with encouraging acute remapping outcomes for pulmonary vein isolation (PVI). However, the long-term durability of PVI and more complex linear lesions remains incompletely defined.
Methods
We identified all consecutive patients who underwent FPFA using the Centauri system for atrial arrhythmias at our institution and subsequently required a clinical repeat procedure with high-density multi-electrode mapping (n=40). FPFA was performed as a first procedure in 11 patients and as a second or subsequent procedure in 29 patients. Lesion durability was assessed at repeat ablation using high-density electroanatomical mapping and pacing maneuvers. Lesions were categorized by type and analyzed accordingly. Clinical recurrence during follow-up was defined as any documented atrial tachycardia or initiation/escalation of antiarrhythmic drug therapy.
Results
Mean age was 67 ± 8 years. The predominant presenting arrhythmia at repeat ablation was atrial flutter (32/40, 80%). Mean procedure time was 107 ± 37 minutes. In total, 125 lesions were evaluated at repeat ablation, performed a mean of 359 ± 229 days after the index FPFA procedure. Durability rates were: PVI 57/75 (76%), posterior wall isolation 12/18 (67%), cavotricuspid isthmus line 10/12 (83%), anteroseptal mitral isthmus line 3/8 (38%), and other linear lesions 6/12 (50%). After a mean follow-up of 289 ± 268 days, 30 patients (75%) remained free from clinical recurrence.
Conclusions
In this selected cohort undergoing repeat ablation for recurrent atrial arrhythmias, including complex atrial tachycardias, FPFA demonstrated moderate long-term lesion durability. Improved substrate characterization, optimization of lesion overlaps, and better understanding of lesion depth and procedural limitations with FPFA are needed to enhance long-term durability and clinical outcomes.