PVI Durability After PFA or RFA in Persistent-AF: Insights From a Mandated Prospective Remapping Study

Durable pulmonary vein isolation (PVI) is the primary objective of atrial fibrillation (AF) ablation, yet reconnections are common and non-PV mechanisms may drive recurrence in persistent AF.

This study sought to compare PVI durability and arrhythmia recurrence between pulsed field ablation (PFA) and radiofrequency ablation (RFA) in persistent AF patients.

Persistent AF patients undergoing PVI were prospectively enrolled, with a mandatory remapping procedure performed after 6 months regardless of recurrence. RFA was used in phase 1 (n = 30) and PFA was used in phase 2 (n = 30). Patients were followed with 7-day Holter electrocardiograms after 3, 6, and 12 months. Primary and secondary endpoints were PVI durability and arrhythmia recurrence.

Of 60 enrolled patients, 51 underwent the mandated remapping procedure after a median of 7.2 months (mean age 68 years; 82% male). PVI was durable in 78 of 102 PVs (76%) with RFA and in 82 of 104 PVs (79%) with PFA (adjusted OR: 1.20; 95% CI: 0.37-3.88; P = 0.77), with lowest durability in the right superior PV (PFA 72%; RFA 69%). All PVs were durably isolated in 26 patients (51%). Of 26 patients (51%) with durably isolated PVs, 9 (35%) experienced AF recurrence prior to the remapping procedure. Of 25 patients (49%) with reconnected PVs, 7 (28%) experienced AF recurrence. At 1-year follow-up, freedom from recurrence after mandated redo procedure was 70% with no difference between the 2 ablation technologies (adjusted HR: 0.80; 95% CI: 0.24-2.64; P = 0.71).

In patients with persistent AF, PFA demonstrated PVI durability comparable to RFA. Arrhythmia recurrence occurred in a substantial proportion of patients with durable PVI, suggesting a role for non-PV mechanisms.