Beyond the learning curve: How operator experience affects pulsed-field ablation outcomes

The learning curve for pulmonary vein isolation (PVI) using "single-shot" pulsed-field ablation (PFA) is thought to be short. Three-dimensional electroanatomic mapping (3D-EAM) might provide adjunctive information to shorten the learning curve and improve lesion durability.

This study aimed to analyze procedural performance markers over time for PVI using PFA and 3D-EAM.

Consecutive patients undergoing PVI with PFA were included. 3D-EAM was used based on the operator's experience and the planned lesion set. Patients were followed using a 7-day Holter electrocardiogram at 3, 6, and 12 months. During clinically indicated repeat ablations, 3D-EAM was used to assess PVI durability.

A total of 1008 patients with atrial fibrillation underwent their first PVI using PFA. 3D-EAM was used in 457 patients (45%). Using an exponential fit function, the learning curve was estimated at 18 procedures for procedure time and 8 for fluoroscopy time per operator. Using a learning curve cutoff of 20 cases per operator, 12-month freedom from arrhythmia recurrence was similar during (n = 224) and after (n = 784) the learning curve (65% vs 68%; P = .52). Similarly, the use of 3D-EAM did not affect outcomes (69% without 3D-EAM vs 64% with 3D-EAM; P = .50). PVI durability increased from 201 of 332 veins (61%; <60 procedures per operator) to 82 of 112 veins (73%) thereafter (P = .017).

Although the learning curve for "single-shot" PFA is approximately 20 cases per operator based on procedure and fluoroscopy times, improvements in long-term PVI durability were observed after 60 cases. No difference in freedom from arrhythmia was observed during the learning curve or by using 3D-EAM.