Pulsed-field ablation versus cryoballoon ablation in patients with persistent atrial fibrillation undergoing first catheter ablation

Abstract Background Catheter ablation (CA) for persistent atrial fibrillation (AF) is more challenging and associated with less favorable outcomes. While early studies showed similar outcomes for pulsed-field ablation (PFA) and cryoballoon ablation in all-comers, the impact of the used ablation modality on clinical outcomes in patients with persistent AF remains unclear. Purpose to compare PFA and cryoablation in terms of procedural characteristics, safety, and efficacy in patients undergoing CA for persistent AF. Method Patients with persistent AF who underwent their first CA at a tertiary referral center using either PFA or Cryo between January 2018 and June 2024 were enrolled. Results 219 patients (median age 67 [60 – 72] years, 26% female) were included. 113 patients (52%) underwent PFA and 106 patients (48%) cryoablation. Median procedure duration, LA dwell time and fluoroscopy time were shorter in the PFA group: 48 [39 – 58] min vs 60 [50 – 74] min (p <0.001), 33 [24 – 42] min vs 37 [31 – 49] min (p <0.001), and 9 [7 – 12] min vs 11 [8 – 16] min (p = 0.008). Overall, there were 5 complications (2%), 3 (3%) in the PFA and 2 (2%) in the Cryo group. 21% of the PFA group received additional posterior wall ablation (PWI). During a median follow-up of 361 days, recurrence-free survival was 71% in the PFA group and 60% in the Cryo group, pLog-rank = 0.117 (Figure). Conclusion In patients with persistent AF undergoing CA, PFA results in increased efficiency, but similar safety and recurrence-free survival rates. Future studies are warranted assessing the role of extended ablation strategies when using PFA such as PWI in patients undergoing CA for persistent AF.Figure