Impact of Pulsed-Field Ablation on the Left Atrial Appendage Diameter-Insights From Intra-Procedural Echocardiography

Concomitant pulmonary vein isolation (PVI) and left atrial appendage (LAA) occlusion (LAAO) have become frequently used therapies. Pulsed-field ablation (PFA), will likely be used for combined PVI plus LAAO procedures. However, there may be concerns regarding the malposition of the LAAO device attributed to the potential tissue edema after PVI.

We aimed to compare the LAA's size before and after PVI performed with the pentaspline catheter, measured intraprocedural by intracardiac echocardiography or transesophageal echocardiography.

We conducted a multicenter, prospective, observational study investigating PVI using the Farapulse system. The anteroposterior diameter of the left-sided pulmonary vein (LPV), left atrial ridge, and LAA were measured before and after the PFA.

We enrolled 91 patients aged 63 ± 10 years, 36% were women, and 47% had paroxysmal AF. The most common comorbidities was hypertension (59%). Procedure time and left atrial dwell time were 65 (52-80) min, and 27 (24-32) min, respectively. The diameter of the LAA was not different before and after the PVI (15 [13-18] and 16 [13-19], respectively; p = 0.756). On the other hand, the diameter of the left atrial ridge (7 [6-8] and 8 [6-8]) and the LPV (13 [10-15] and 13 [11-15]) was smaller before ablation compared to the diameter after PVI (p < 0.0001 for both). No major complications occurred.

LAA anteroposterior diameter does not change after PVI with PFA. Although there is a significant change in the anteroposterior diameters of the LPV and the left atrial ridge, it does not seem clinically relevant. If significant edema formation is detected in a single case after PVI, postponing the LAAO procedure should be considered.