Findings from repeat ablation using high-density mapping after pulmonary vein isolation with pulsed field ablation

Abstract

Aims Pulsed-field ablation (PFA) can offer a novel perspective for atrial fibrillation (AF) ablation. We aimed to characterize the incidence of pulmonary vein (PV) reconnection, types of recurrent atrial tachyarrhythmia (ATa) and lesion quality after PFA-guided PV isolation (PVI). Methods and results Patients undergoing second ablation for recurrent ATa following the initial PVI using the pentaspline PFA catheter were investigated. The rate of PV reconnection, the features of recurrent ATa, and the amount of isolated posterior wall (PW) surface area (ISAPW%) (ratio of the isolated- to total surface area on PW) were analyzed. Results Among 360 patients treated with PFA, 25 patients (paroxysmal AF, n = 19) with 99 PVs underwent a second procedure 6.1 ± 4.0 months after the initial procedure. The rate of PV reconnection was 9.1% (9 PVs). Patients presented with atrial tachycardia (AT) (n = 16), AF (n = 8) and typical atrial flutter (n = 1). The mechanism of all but one AT was macro-reentry. The critical isthmus was found to be linked to the initial lesion set at the left atrial (LA) PW in eight patients and linked to pre-existing substrate at the LA anterior wall in four patients. One AT had a focal origin at the septum. In three patients, AT were unmappable. Mean ISAPW% was 72.7 ± 19.0%. Conclusion We revealed a remarkable low reconnection rate with a large antral lesion at the PW after pentaspline PFA catheter-guided PVI. However, macro-reentrant AT with a critical isthmus at the LAPW linked to the PVI lesion set was commonly observed.

Pulsed Field Versus Cryoballoon Pulmonary Vein Isolation for Atrial Fibrillation: Efficacy, Safety, and Long-Term Follow-Up in a 400-Patient Cohort

“…If confirmed in larger studies, this may represent a sign of a recurrence shift after PVI, with arrhythmia recurrence less related to PV reconnection and more related to man-made tachycardias, as suggested by our observation of a corridor of slow conduction in the posterior wall between the PV ostia after PFA ablation. 24…”

Acute lesion extension following pulmonary vein isolation with two novel single shot devices: Pulsed field ablation versus multielectrode radiofrequency balloon

“…Our data demonstrating 3D-mapping-based larger antral lesions in the PFA cohort are in line with the previous findings and provide an explanation for the higher number of postablation atrial tachycardia in the PFA group. 13 We believe that the higher occurrence of postablation atrial tachyarrhythmias in this group is dependent on lesion-size rather than on the energy source itself.…”

“…What is known from previous studies is that a wide antral approach is more effective than ostial PVI in achieving freedom from atrial tachyarrhythmia recurrence at long‐term follow‐up 12 . However, as recently described by Tohoku et al, 13 PVI based on the pentaspline PFA catheter can be associated with postablation macro‐reentrant atrial tachycardia with a critical isthmus at the LA posterior wall. Our data demonstrating 3D‐mapping‐based larger antral lesions in the PFA cohort are in line with the previous findings and provide an explanation for the higher number of postablation atrial tachycardia in the PFA group 13 .…”

Pearls and Pitfalls of Pulsed Field Ablation

“… 26) Others confirmed the advantage of the novel waveform in patients who necessitated redo procedure after initial PFA-PVI: solely 9.1% of PV showed reconnection. 85) Additional works reported that the chronic antral lesion size created with PFA (pentaspline catheter) persists over time 72) and is comparable to the ones with RF, cryo- or laserballoon ablations. 86) Interestingly, in an MRI study, most of the large late gadolinium enhancement (LGE) lesions acutely induced by PFA disappeared over time, whereas those persisted after RF- or cryoablation, e.g., caused chronic fibrosis.…”