Real-Time 3D Mapping Corrects Fluoroscopic Misperception During Pulmonary Vein Isolation by Pulsed Field Ablation

Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) is mainly guided by fluoroscopy. A novel electroanatomical module enables real-time 3D mapping (3D-EAM) integrated with the PFA catheter.

To assess the contribution of 3D-EAM to pulmonary vein (PV) targeting accuracy and lesion coverage during PFA.

Among 66 consecutive prospective cases, two sequential phases were conducted: a 3D-blinded mapping phase (n = 21), in which anatomical maps were created but withheld from operators, and a real-time 3D-EAM guidance phase (n = 45), where live mapping was used during ablation. A retrospective cohort of fluoroscopy-only PFA procedures (n = 77) served as a control. Lesion coverage and procedural metrics were compared across groups, and post-procedural operator assessments were collected in the 3D-blinded phase.

In the 3D-blinded phase, 5 of 21 procedures (23.8%) failed to isolate at least one PV during the first attempt. Additionally, 47.6% of operators reported they would have altered their strategy using 3D-EAM guidance. Overall lesion coverage was judged satisfactory in 77 of 84 PVs (91.5%). In the real-time 3D-EAM phase, no veins were missed. Compared with fluoroscopy-only and 3D-blinded procedures, 3D-EAM guidance significantly reduced the number of PVI applications (33.6 ± 7.8 vs. 38.4 ± 9.0 and 39.3 ± 10.5; p = 0.007) but increased left atrial dwell time (23.6 ± 7.2 vs. 16.7 ± 4.3 min; p < 0.001).

Real-time 3D-EAM guidance improved PV targeting, reduced unnecessary applications, and eliminated missed veins. Integration of 3D mapping into PFA workflows is safe, feasible, and may enhance procedural quality. Larger studies are warranted to determine effects on long-term arrhythmia recurrence and durability.