Pulsed field ablation using additional mapping and substrate modification to treat atrial fibrillation - one year outcome comparison

Abstract Background Pulsed field ablation (PFA) is a relatively new non-thermal form of ablation employing irreversible cell electroporation as an alternative to radio-frequency ablation. Conventional use of PFA relies on fluoroscopy. Electro-anatomical and voltages mapping (EAM) may potentially provide refinement of PFA via ablation of non-PV targets and accurate localisation of catheter placement. Currently there is limited data on the efficacy of the use of voltages criteria of EAM in conjunction PFA in the treatment of atrial fibrillation. Objective The aim of our study was to determine the effect on atrial arrhythmia recurrence with the use of EAM with PFA in patients requiring atrial fibrillation ablation. Methods This single centre retrospective observational analysis included one hundred patients with symptomatic AF (paroxysmal and persistent) undergoing ablation for the first time. Fifty patients underwent PFA-PVI alone and fifty patients underwent PFA-PVI with EAM. Data were obtained on patient characteristics, outcomes, procedure details and complications up to one year. A blanking period of three months was used post-ablation. For rhythm monitoring we utilised ECGs and holters at three, six, nine and twelve months and twenty-four hour holter monitoring at six and nine months. We also used remote monitoring in between these periods to record any symptomatic episodes atrial arrhythmias. Results Baseline patient characteristics are represented in Table 1. Despite having no significant difference in category of AF between groups (Paroxysmal, persistent, longstanding persistent) the mapping group were significantly older (68.2 years ± 10.2 vs 60.1 ± 11.11; p=0.01), longer duration of documented atrial fibrillation (45.9 ± 50 vs 28.6 ± 38 months; p=0.038), higher risk for CV events with CHA2DS2-VASc score (2.2 ± 1.5 vs 1.42 ± 1.2; p=0.04), however, procedure times were greater in the PVI and mapping group (72.8 ± 6.2 vs 41.1 ± 17 minutes; p=0.03). Successful PVI was achieved acutely in all patients upon voltage guided mapping validation and most importantly 1 year follow up revealed comparable outcome in both groups (Fig 1). Conclusion Patients who underwent PFA with mapping were older, greater co-morbidity and longer duration of AF burden. Yet, the addition of EAM with PFA did demonstrate equivalent achievement of sinus rhythm and was relatively high as higher than 80 % at one year follow up. This study may suggest a preference to using EAM in patients who may be deemed to be older and have a greater co-morbidity. It emerges as a great hope to safer approach and successful intervention to reduce AF burden.mapping vs PVI onlyGraph showing one year follow up