Ablation in persistent atrial fibrillation: High long-term success with pulsed field ablation using a strict protocol

Posterior wall isolation (PWI) is often performed in addition to pulmonary vein isolation (PVI) during ablation of persistent atrial fibrillation (PersAF) to decrease recurrence. However, in studies using radiofrequency energy, the addition of PWI failed to demonstrate improved outcomes compared with PVI alone, possibly owing to challenges in achieving durable PWI. PWI with pulsed field ablation (PFA) results in high rates of durable PWI.

We hypothesized that PVI plus PWI, performed with tissue-contact visualization with intracardiac echocardiography (ICE) and confirmation with high-output pacing, would effectively treat PersAF.

We studied consecutive patients with PersAF undergoing their first ablation with PFA. PVI and PWI were conducted with the FARAPULSE system using a strict protocol that included (1) continuous tissue-contact visualization with ICE and (2) confirmation of PVI and PWI with high-output pacing.

A total of 109 consecutive patients with PersAF (age 70 years [interquartile range 64-75]; 30 females [27.5%]; CHA₂DS₂-VA score 2.5 ± 1.5) were studied. PVI and PWI were achieved in all patients without complications (procedure time 84 ± 12 minutes; dwell time 48 ± 10 minutes; mean PFA applications 58 ± 3.8; fluoroscopy time 14 ± 8 minutes). The mean follow-up was 15.8 ± 5.5 months. At 12 months, freedom from recurrent atrial arrhythmias was achieved in 79 patients (72%). Eight patients opted for a second ablation. Durable PVI was confirmed in 90% of veins, and persistent PWI was confirmed in 87% of patients.

A high long-term success rate of ablation is achievable in PersAF with PFA and tissue-contact confirmation using ICE.