Pulsed field ablation for pulmonary vein isolation with or without posterior wall ablation in patients with...

Posterior wall ablation (PWA) is frequently performed during pulsed field ablation (PFA) of persistent atrial fibrillation (pe-AF), despite unclear evidence. We aim to study the safety and efficacy of PWA, compared to pulmonary vein isolation (PVI) alone, in this population.

In this multi-center study, we included all patients with pe-AF who underwent PFA from April to November, 2024. Clinical records were retrospectively reviewed for demographics, procedural details, and clinical outcomes.

During the study period, 387 patients with pe-AF underwent PFA (mean age 68.7 years, 32.0% female, 80.1% PWA). At a mean (standard error of the mean) follow-up of 12.1 (0.3) months, arrhythmia recurrence was 19.5% for PVI and 26.8% for PVI + PWA (p = 0.19). In multivariable Cox proportional hazards models, PWA was not independently associated with arrhythmia recurrence (adjusted hazard ratio [aHR] 1.36; 95% confidence interval [CI] 0.77-2.39) or with pe-AF recurrence requiring additional rhythm control strategies (aHR 1.08; 95% CI 0.57-2.05). Of the recurrences after PWA, 25.3% were with atrial flutter/tachycardia (AFL/AT). In a time-varying Cox analysis, there was evidence of treatment-effect non-proportionality (p = 0.02). PWA was not associated with recurrence 90-190 days post-ablation (aHR 0.78; 95% CI 0.40-1.53), but was associated with higher recurrence hazard thereafter (aHR 3.13; 95% CI 1.10-8.87).

PWA was not associated with atrial arrhythmia recurrence in patients with pe-AF. More recurrences in the form of AFL/AT, in combination with a late increase in recurrence hazard, may be indicative of a potential for re-entry after PWA.