Single-shot pulmonary vein isolation: a comparison of pentaspline pulsed field ablation versus radiofrequency- and cryoballoon

Abstract Background Pulmonary vein isolation (PVI) using single-shot devices is an established interventional treatment for patients with atrial fibrillation (AF). The primary energy modalities for PVI include radiofrequency (RF), cryoballoon (CB), and pulsed field ablation (PFA). This retrospective analysis compares the efficacy and safety of pentaspline PFA versus CB and RF-balloons. Methods The study included 110 patients (mean age 60-62 years) with paroxysmal or persistent AF who underwent ablation using the Heliostar® (Biosense Webster) RF balloon (38 pts.), the ArcticFront cryoballoon (37 pts.), or Farapulse pentaspline PFA system (35 pts.). Demographic and procedural data were collected and analyzed to analyze intergroup comparisons. Patients were followed 3, 6 and 12 months after PVI and were advised to undergo ECGs upon experiencing symptoms (palpitations or tachycardia) after the ablation. Results Demographic variables were comparable among all groups. In each patient, PVI was achieved in all pulmonary veins. Intraprocedural cardioversion was necessary in 5% of CB cases, compared with 23% in the RF and 34% in the PFA group. The RF group showed the longest procedure duration (105 min) - specifically due to additional electroanatomical mapping - whereas interventions in the PFA group were significantly shorter (84 min; Fig 1). Fluoroscopy duration was consistent across groups, but RF had the lowest dose-area product. Complications occurred less frequently in the RF-balloon (2.7%; 1 air embolism) and PFA group (5.7%; 1 tamponade, 1 access complication) compared with in the Cryo group (13%; 4 transient phrenic nerve palsies). Mean follow-up duration was longer in the cryoballoon (590 days) and the RF-balloon (500 days) vs. PFA (250 days) groups. Arrhythmia recurrence within 90 days was lowest in the PFA group (14%), compared with RF (21%) and CB (19%). Hospital admissions and total arrhythmia recurrence rates were similar across groups (6–9%), with five redo procedures performed in the entire cohort. Overall success rates off AA drugs were high: Cryoballoon at 90.5%, RF-balloon at 91.2%, and PFA at 94.1% (Fig 2). Conclusion PVI demonstrated effectiveness and safety across all three single shot ablation systems. The addition of electroanatomical mapping in the RF-balloon system increased procedure time but added information during ablation. In terms of safety and efficiency, PFA systems performed non-significantly more favorably. However, for patients with complex anatomy or redo procedures, a hybrid approach including electroanatomical mapping may further optimize clinical outcomes.Procedure duration Recurrences