Safety, efficacy and reproducibility of a simplified strategy to achieve pulmonary vein isolation using radiofrequency ablation
O Bastidas, J E Marin, L M Ruiz, C Nino, J M Aristizabal, W Borja, D Ocampo, A Salazar, N Mejia, M Duque, B Ramirez, A C Gallo, C Lopez, J F Llano, J DiazAbstract
Introduction
Pulmonary vein isolation (PVI) is currently the cornerstone for atrial fibrillation (AF) ablation, with point-by-point radiofrequency ablation (RFA) frequently performed. By reducing interlesion distance, PVI can be improved and other frequently used strategies (waiting period, adenosine testing, remapping) can be avoided without any impact on procedural outcomes.
Purpose
To describe the safety, efficacy and reproducibilility of a simplified approach to pulmonary vein isolation, based on the use of an interlesion distance of 3 mm.
Methods
Patients undergoing first-time PVI between January 2022 and May 2025 were included. PVI was performed using point-by-point RFA under general anesthesia using high-frequency low-tidal volume ventilation, performing wide antral catheter ablation using 40W. The simplified approach included: 1. Two femoral venous accesses through the right groin (1 for the transeptal sheath, 1 for intracardiac echocardiography); 2. A single transeptal puncture; 3. PVI with a target interlesion distance of 3 mm; 4. Evaluating entrance and exit block using the ablation catheter. All ablations were performed guided by lesion indexes; lesion contiguity in the posterior wall was not obligatory, to avoid heat stacking. If first pass isolation was not achieved, additional lesions were delivered at the site of earliest activation. Patients were followed with holter monitoring or device interrogation at 3,6,12 months, and every 6 months thereafter.
Results
A total of 771 patients (female n=264, age 62.5±11.4 years) were included (Table 1). Persistent AF was present in 321 (41.6%) of patients, severe left atrial dilation (defined as a left atrial indexed volume ≥48 mL/m2) in 158 (20.5%), heart failure in 173 (22.4%), and an implantable cardiac electronic device in 116 (15%) patients. Procedural time was 100[78-130] min., with 48.6% of cases performed without fluoroscopy. During follow-up, there were no cases of atrial-esophageal fistula, with 3 patients (0.4%) presenting pulmonary vein stenosis which did not require intervention. At 1-year follow-up, 86% of patients were free from all atrial arrhythmia recurrence. To evaluate reproducibility, we evaluated if operator experience or fellow participation during the ablation had a significant impact on arrhythmia recurrence. There were no significant differences in patients characteristics for any of the comparison groups. During follow-up, there were no significant differences in outcomes when comparing by operator experience (Figure 1A) or by fellow participation during the ablation procedure (Figure 1B).
Conclusions
A simplified approach relying on minimal interlesion distance while eliminating waiting periods, adenosine testing, and remapping, is both safe and effective during RFA PVI, demonstrating a low rate of arrhythmia recurrence. Moreover, similar results are observed irrespective of operator experience or fellow participation during the ablation procedure.Table 1Figure 1