Cavotricuspid isthmus (CTI) ablation with a linear pulsed field ablation (PFA) catheter was associated with safety and efficacy similar to radiofrequency ablation (RFA) and greater efficiency in treating patients with persistent atrial fibrillation (AFib), based on findings from a subanalysis of the ADVANTAGE AF study published in JACC and simultaneously presented at the 31st Annual International AF Symposium in Boston.

The substudy, authored by Edward P. Gerstenfeld, MD, MS, FACC; Boris Schmidt, MD; et al., compared lesion characteristics, CTI ablation efficacy and safety between patients who underwent ablation performed with RFA (N=50) or bipolar linear PFA (N=141).

Overall findings showed acute CTI conduction block was similar between RFA (100%) and PFA (98.6%), as were safety event rates (RFA 2% vs. PFA 2.1%). Procedure duration was shorter with PFA compared with RFA (median: RFA 14 min vs. PFA 5 min). Additionally, no clinical manifestation of coronary artery spasm was observed in patients who underwent PFA ablation and who had received nitroglycerin pretreatment.

“This subanalysis of ADVANTAGE AF extends the primary results by allowing comparison of bipolar linear PFA and RF ablation for CTI, integrating preclinical lesion modeling with clinical dosing, and establishing a standardized reliable coronary safety protocol,” said Gerstenfeld and colleagues. Although not a randomized comparison, they add that the findings “may extend electroporation from the pulmonary veins to linear substrates, and allow a single nonthermal ablation platform for treatment of [AFib and atrial flutter].”

In a related editorial comment, Ayman A. Hussein, MD, FACC, and Oussama M. Wazni, MD, write that “PFA marks the beginning of a new era for cardiac electrophysiology,” noting that wide adoption has “outpaced scientific evidence because of enhanced safety and efficiency vs. thermal ablations.” They suggest that future improvements and research should look at long-term effects of PFA, as well as improving PFA lesion size prediction and opportunities to further integrate with advanced imaging and mapping modalities.