Impact of left atrial posterior wall ablation using pulse field energy on persistent atrial fibrillation

Abstract Background Left atrial posterior wall ablation (LAPWA) has not demonstrated a long-term benefit in terms of efficacy when added to pulmonary vein isolation (PVI) in patients with symptomatic persistent atrial fibrillation (PersAF) undergoing a de novo catheter ablation. There is few data comparing the conventional strategy of PVI with radiofrequency (RF) versus PVI plus LAPWA with pulse field ablation (PFA) in this group of patients. Purpose To compare the strategy of PVI with RF versus PVI plus LAPWA with PFA as an initial approach of ablation in patients with symptomatic PersAF. Methods Consecutive patients with symptomatic PersAF who underwent PVI plus LAPWA using PFA were retrospectively analyzed. The results were compared with a historical cohort of consecutive patients with symptomatic PersAF who underwent PVI using RF as first line of treatment. Patient underwent clinical follow-up with 24-h Holter ECGs at 3, 6, and 12 months postablation. The primary efficacy and safety end-points were freedom from any supraventricular arrhythmia recurrences in 1-year of follow-up after a 3-months blanking period and from any major procedure related complications. Results A total of 38 patients with symptomatic PersAF underwent an initial approach of PVI + LAPWA. The historical control group was a cohort of 108 patients treated with PVI using a state of the art RF approach. The 1-year freedom from atrial arrhythmia was significatively higher in the PFA group than in those patient with the conventional RF strategy (81.6% vs 66%, log-rank test p = 0.0471). Major adverse events occurred in 1 patient in PFA group and 3 patient in the RF group (2.63% vs 4.59%). Conclusion PFA strategy with PVI and LAPWA as an initial approach in patients with symptomatic PersAF showed a beneficial impact on 1-year freedom from any atrial arrythmia compared to the RF ablation approach, with a lower rate of major complication. Randomized study are needed to address the long term effectiveness of this strategy.The 1-year freedom from AF/AT