Technological evolution as an independent predictor of pulmonary vein durability after radiofrequency ablation

Introduction

Pulmonary vein (PV) isolation (PVI) is the most effective interventional therapy for atrial fibrillation. However, achieving durable PVI has remained a major technological challenge. As a result, PV reconnection is frequently observed during redo procedures for recurrent arrhythmia, reflecting the limitations of earlier ablation techniques. Over the past decade, continuous refinement of radiofrequency (RF) ablation technology has aimed to overcome these limitations and improve long-term lesion durability.

Purpose

To evaluate the impact of progressive technological evolution in RF ablation over the past decade on the rate and extent of PV reconnection after PVI.

Methods

We retrospectively analysed the demographic, echocardiographic, and procedural data of patients who underwent point-by-point RF PVI between 2013 and 2024. The analysis focused on the RF technology used during the index procedure, clinical outcomes during follow-up, and the presence of PV reconnection at redo interventions. RF technology was categorised using a scoring system in which conventional irrigated-tip RF catheter ablation represented the baseline (0 points), and each additional technological refinement—contact-force sensing, steerable sheath, Ablation Index guidance, and high-power short-duration RF—added 1 point, yielding a maximum of 4 points.

Results

During the study period, 1,560 patients underwent point-by-point RF PVI (60.5 % male, mean age 62.3 ± 10.6 years). Among them, 351 patients (22.5 %) required redo procedures during a mean clinical follow-up of 2.3 ± 2.4 years.

An inverse correlation was observed between the technology score of the index PVI and both the incidence and extent of PV reconnection. The rate of reconnection decreased progressively across the five technological categories—90 %, 88 %, 74 %, 60 %, and 36 % for scores 0 to 4, respectively (p < 0.001). Likewise, the mean number of reconnected veins per patient declined with increasing score (1.95, 1.82, 1.50, 1.19, and 0.93, respectively; p < 0.001).

In multivariable logistic regression—including demographic, echocardiographic, and clinical covariates—the technology score independently predicted PV reconnection (OR 0.39, 95 % CI 0.23–0.66, p < 0.001), while age, sex, comorbidities, and left atrial diameter were non-significant predictors.

Conclusion

Across a decade of evolving RF ablation practice, technological advancement proved to be an independent predictor of PV durability. These findings confirm that durable lesion formation, rather than patient profile, determines long-term PVI success and establish a procedural durability benchmark for future ablation technologies.