Pulsed-field ablation versus cryoballoon ablation in patients with persistent atrial fibrillation

Current thermal energy sources such as cryoballoon (Cryo) ablation technology are associated with high rates of reconnected pulmonary veins (PV), especially in patients with persistent atrial fibrillation (AF). Pulsed-field ablation (PFA) may represent a more suitable ablation modality for this patient population. This study aims to compare the efficacy, and safety of PFA and Cryo in patients undergoing a PVI only approach for persistent AF.

Patients with persistent AF who underwent PVI at a tertiary referral center using either PFA or Cryo were consecutively enrolled.

A total of 220 patients (median age 66 [60-72] years, 24 % female) were included out of which 113 patients (51 %) underwent PFA and 107 patients (49 %) Cryoablation. Median procedure duration, LA dwell time and fluoroscopy time were shorter in the PFA group: 49 [39-61] min vs 60 [49-75] min (p < 0.001), 34 [25-43] min vs 37 [31--53] min (p < 0.001), and 9 [[8], [9], [10], [11], [12], [13]] min vs 11 [[8], [9], [10], [11], [12], [13], [14], [15], [16]] min (p = 0.008). During a median follow-up of 365 days, recurrence-free survival was 72 % in the PFA group and 60 % in the Cryo group (p_Log-rank = 0.079). The change in AF type from persistent AF to paroxysmal AF was more frequently observed after PFA than after Cryo (68 % vs 37 %; p = 0.011).

In patients with persistent AF undergoing a PVI only approach, PFA was associated with shorter procedural times and similar efficacy, with a higher frequency of regression from persistent to paroxysmal AF. Future studies are needed to evaluate the role of ablation strategies beyond PVI when using PFA.