Acute kidney injury after catheter ablation of atrial fibrillation: comparison between different energy sources

Abstract Introduction Pulsed field ablation (PFA) is an innovative technology recently adopted for the treatment of atrial fibrillation (AF). Preclinical and clinical studies have reported a reassuring safety profile, because of its tissue specific effect, sparing adjacent tissues. However, two cases of acute kidney injury (AKI) secondary to hemolysis after PFA have recently been reported. Purpose To compare the incidence of AKI and hemolysis after catheter ablation of AF using radiofrequency energy (RFA), cryo-balloon energy (CBA) and PFA using a pentaspline catheter. Method Patients undergoing catheter ablation of AF were consecutively enrolled in a prospective registry in a tertiary referral center between April 2010 and January 2024. Blood samples including renal parameters and hemolysis indicators were obtained prior to the procedure and the day after the procedure. AKI was defined as an increase in serum creatinine by 26.5 µmol/L within up to 10 days after the procedure . Results A total of 2602 patients (median age 64 years, 29.4% female) underwent catheter ablation for AF. 1707 (66.4%) were treated with RFA, 557 (21.7%) using CBA and 306 (11.9%) using PFA. Median net duration of ablation was 1669 (IQR 1207, 2164) seconds for RFA, 1046 (IQR 840, 1451) seconds for CBA and, 80 (IQR 48, 85) seconds (32 (IQR 19, 34) applications) for PFA. AKI was found in 21 (0.012%), 1 (0.002%) and 1 (0.003%) patients treated with RFA, CBA and PFA, respectively, p=0.245. The case with AKI after PFA received a total of 86 PFA applications. There was a significant positive correlation for the RFA group between the ablation duration and the creatinine level after the procedure, while there was no positive correlation for the CBA and PFA group (Figure). At least one hemolysis indicator (Bilirubin, LDH or Urea levels) was elevated the day after the procedure in 53.1%, 50.1% and 46.5% in the RFA, CBA and PFA group, respectively, p=0.12. Conclusion AKI appears to be very rare after PFA and comparable to thermal energy forms. Hemolysis does not seem to be dependent on the used energy source for pulmonary vein isolation. Minimal hemolysis occurs when PFA is applied as recommended by the manufacturer.Graphical Abstract