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Durability of Pulmonary Vein Isolation Using Pulsed-Field Ablation
Quick Takes
- In the EU-PORIA registry of pulsed-field ablation for AF, 23% of patients had an arrhythmia recurrence, and 12% of patients underwent a left atrial redo procedure.
- Among the 144 patients undergoing a redo procedure, durable pulmonary vein isolation (PVI) was noted in 71% of the pulmonary veins; 38% of patients had evidence of durable PVI in all veins.
- Operator experience with cryoballoon ablation was associated with higher PVI durability compared to operators with only point-by-point radiofrequency experience.
Study Questions:
What is the real-world lesion durability of pulmonary vein isolation (PVI) with pulsed-field ablation (PFA) among patients with clinically indicated redo procedures?
Methods:
The authors analyzed patient data from the EU-PORIA registry, which had enrolled patients with atrial fibrillation (AF) undergoing PVI using PFA. In patients with subsequent left atrial redo procedures, PVI durability was assessed, and sites of reconnections and predictors of lesion durability were identified.
Results:
Of 1,184 patients undergoing PVI using PFA, 272 (23%) had an arrhythmia recurrence. Of these, 144 (12.5%) underwent a left atrial redo procedure. Left atrial mapping identified 404/567 (71%) pulmonary veins with durable isolation. In 54 (38%) patients, all pulmonary veins were durably isolated. Prior operator experience with cryoballoon ablation was associated with a higher PVI durability compared to operators with only point-by-point radiofrequency experience (76% vs. 60%, p < 0.001). Neither the operators’ cumulative experience in AF ablation nor the size of the PFA device used had an impact on lesion durability.
Conclusions:
The authors conclude that among patients with arrhythmia recurrence after PFA PVI who undergo a redo procedure, durable isolation was observed in 71% of the pulmonary veins during the redo procedure, and 38% of all patients showed durable isolation of all veins.
Perspective:
PFA is a novel nonthermal ablation technology, in which electroporation of the cardiac tissue results in cell membrane disintegration and necrosis. Pulmonary vein reconnections resulting from the inability to achieve durable PVI are one of the major factors for suboptimal ablation results, be it in patients treated with radiofrequency ablation or cryoablation. Premarket studies of the PFA showed very high PVI durability during mandatory remapping studies 3 months after PVI using PFA.
The current study is the real-world assessment of lesion durability in patients with arrhythmia recurrence during a redo procedure. The authors of the present study showed that 71% of the pulmonary veins were isolated, and that durable isolation of all PVs was found in 38% of the patients. For comparison, for repeat ablation after radiofrequency or cryoablation, studies reported a durability of 46-64% on a vein level and 10-30% on a patient level. Improvement of the workflow with integration of a 3D-electroanatomic mapping and intracardiac echo may help. It may be necessary to adjust the dose of the pulse-field ablation for different sites in the left atrium. Future studies are needed to improve pulmonary vein durability with PFA.
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Ablation, Atrial Fibrillation
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