The olive strategy: an improved ablation protocol for the pentaspline pulsed field ablation catheter

Abstract Background The pentaspline pulsed field ablation (PFA) catheter is increasingly used worldwide for pulmonary vein isolation (PVI) to treat atrial fibrillation (AF). The current standard ablation protocol consists of 8 applications per pulmonary vein (PV) with two different catheter configurations: 4 applications with a flower and 4 applications with a basket shape. So far, data from remapping procedures shows PV reconnection rates that are not superior to those after conventional thermal ablation. Purpose We sought to improve the durability of PVI with the pentaspline PFA catheter. To achieve this, we extended the ablation protocol to 10 applications per PV. We added 2 applications with a small olive shaped catheter configuration (Figure 1). Methods Consecutive patients who underwent PVI using the olive strategy between 06/2023 and 07/2024 were included. Procedural data and safety data were analyzed. In patients who underwent repeat procedures for recurrent arrhythmia, durability of PVI was analyzed and compared to remapping data from patients who were ablated using the conventional 8-application strategy in our center. Additionally, recurrence of atrial arrhythmia was assessed for the first 100 olive patients and compared to 100 propensity score matched conventional patients. Results A total of 400 olive strategy patients (mean age 67.2 years, 64% male, 60.2% paroxysmal AF) were included. PVI was successfully achieved in all patients with a mean procedure time of 33.7 minutes and mean fluoroscopy time of 7.5 minutes. Procedure related complications occurred in 11/400 patients (2.75%). Pre- to postprocedural estimated glomerular filtration rate (eGFR) did not change significantly (mean pre: 72.25 ml/min/1,73 m2, mean post: 73.09 ml/min/1,73 m2, p = 0.19). No case of acute kidney injury occurred. In repeat procedures, PV reconnection was significantly less frequent after olive PVI compared to conventional PFA PVI (Figure 2). After olive PVI, 13.6% (3/22) of patients had at least one reconnected PV, compared to 45% (36/80) of patients after conventional PVI (p = 0.007). Overall, only 4.6% (4/87) of all PVs were reconnected in the olive group compared to 20.2% (64/317) in the conventional group (p < 0.001). PV diameters assessed through angiograms did not decrease after olive PVI (pre-PVI mean 19.99 mm, post-PVI mean 20.09 mm, p = 0.51). Freedom of arrhythmia at 180 days after the procedure was not different between the first 100 olive patients (86%) and 100 propensity score matched conventional patients (87.3%, p = 0.75). Conclusions The novel olive strategy for the pentaspline PFA catheter significantly improves durability of PVI and is safe to use. Our data show neither PV stenosis nor acute kidney injury as a potential sign for hemolysis due to additional pulsed field applications. Longer follow-up data will be available in future and may reveal, whether improved PVI durability leads to improved clinical outcomes.Pentaspline PFA catheter shapes Pulmonary vein isolation durability