Pulmonary vein isolation using a novel balloon-in-basket pulsed field ablation system: The Lübeck how-to protocol

Single-shot pulsed field ablation (PFA) is increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). Although balloon-in-basket (BiB)-PFA system integrates ablation and mapping into a single catheter, standardized procedural workflows remain limited.

This study aimed to describe a standardized, step-by-step workflow for AF ablation using the BiB-PFA system and evaluate procedural performance, acute safety, and the learning curve in clinical practice.

This prospective, single-center study included 40 consecutive patients undergoing index PVI using the BiB-PFA system at a tertiary high-volume electrophysiology center. Procedures followed standardized protocol including balloon preparation, ultrasound-guided access, fluoroscopy-guided transseptal puncture, selective pulmonary vein (PV) angiography, and a structured 2-step ablation approach for each vein. Posterior wall ablation (PWA) was performed in selected patients. Procedural metrics and acute complications were analyzed descriptively.

Patients were 64.5 years old (56.5, 73.3); 41% were female, and 57.5% had nonparoxysmal AF. The median procedural duration was 41.5 minutes (35.0, 59.0), left atrial dwell time 27.5 minutes (25.0, 36.0), and BiB dwell time 23.0 minutes (20.0, 25.8). A median of 4 applications per PV was used. Reduced-energy delivery was required in 30% of right inferior and 25% of right superior PV. PWA was performed in 35% of patients using a median of 5 applications. No major intraprocedural complication occurred. The mean procedural duration decreased from 50.0 minutes (38.0, 60.5) in the first 10 cases to 34.5 minutes (31.5, 52.0) in the last 10 cases (P = .059).

A standardized BiB-PFA workflow enables efficient, safe, and reproducible PVI with optional PWA and can be rapidly implemented during early operator experience.