Posterior wall lesion extension following PVI with PFA, cryoballoon, and RF: skill-driven or system-driven?
L Cobarro Galvez, L G B Gomez-Burgueno, M N C Negreira-Caamano, I L A Lopez-Alacid, E A R A M Rajjoub Al-Mahdi, A M C Marco Del Castillo, J R J Ramos Jimenez, L B B Borrego Bernabe, J D J Delgado Jimenez, R S B Salguero Bodes, F A Y Arribas Ynsaurriaga, D R M Rodriguez MunozAbstract
Background
Pulmonary vein isolation (PVI) using radiofrequency (RF), cryoballoon (CB), or pulsed field ablation (PFA) achieves comparable efficacy in atrial fibrillation. However, lesion extension on the left atrial posterior wall (LAPW) may differ across technologies, and broader lesions reported with pentaspline PFA (P-PFA) have raised concerns about narrow residual viable corridors.
Methods
Consecutive patients undergoing repeat left atrial (LA) mapping after initial PVI with P-PFA, CB, or RF were included. Cases with additional LA ablation, posterior wall scarring, or non-durable PVI were excluded. LAPW isolated area (primary endpoint), percentage of LAPW isolated, and residual corridor width (secondary endpoints) were analyzed. Examples of LAPW delineation and isolated regions for RF, CB, and P-PFA are shown in Figure 1A–1C.
Results
A total of 100 patients were included. A detailed summary of patients characteristics and all primary and secondary endpoints is provided in Figure 2.
P-PFA and CB ablation produced similar degrees of LAPW isolation. The isolated LAPW area was comparable between both modalities (8.3 ± 4.0 vs 9.5 ± 3.9 cm²; p = 0.601), and the percentage of LAPW isolated was nearly identical (39.9 ± 17.6% vs 38.9 ± 14.9%; p = 1.000). RF ablation showed a trend toward smaller isolated LAPW area (6.1 ± 3.9 cm²), although this difference compared with P-PFA did not reach statistical significance (p = 0.087). However, the percentage of LAPW isolated with RF was significantly lower than with P-PFA (29.5 ± 18.4% vs 39.9 ± 17.6%; p = 0.043 after Bonferroni correction). CB ablation isolated a significant larger LAPW area than RF (9.5 ± 3.9 vs 6.1 ± 3.9 cm²; p = 0.007 after Bonferroni correction).
Analysis of residual corridors revealed that P-PFA and CB generated similarly narrow viable pathways (19.4 ± 9.9 mm and 18.6 ± 10.9 mm; p = 1.000), both significantly narrower than those left after RF ablation (26.9 ± 8.1 mm; p = 0.009 and p = 0.010, respectively, after Bonferroni correction). These findings indicate that although overall isolated area was comparable between energy sources, the geometric pattern of lesions differed.
Conclusion
P-PFA produced LAPW isolation comparable to CB and a higher relative isolation percentage than RF. These findings suggest that posterior wall involvement is influenced more by catheter geometry and deployment mechanics than by the ablation energy itself, highlighting the need to optimise deployment strategies to minimise unintended LAPW ablation.Patients characteristics and endpoints.Examples of LAPW delineation.