Thermal- versus nonthermal-based pulmonary vein isolation in young adults with paroxysmal atrial fibrillation: 1-year results of a multicenter registry

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. When performed with thermal energy sources (cryoballoon, radiofrequency), PVI leads to collateral damage to major ganglionated plexi (GP); GP are a conglomeration of autonomic ganglia on the epicardial surface of the heart, which have been reported to play a critical role in initiation and maintenance of AF. The role of GP is considered particularly important in younger AF patients. Pulsed field ablation is a novel non-thermal energy source for PVI with only transient effects and no collateral damage to GP. Purpose to compare the outcomes of pulsed field ablation (PFA) and cryoballoon ablation (CBA) in paroxysmal AF (PAF) patients under 50 years of age across four high-volume centers in Europe. Methods We prospectively enrolled consecutive PAF patients who underwent first-time PVI via a pentaspline PFA catheter between January 2022 and May 2024 or a second-generation CBA between January 2017 and May 2024. Patients under 20 years of age were excluded. For the purpose of the study, a cut-off of 1-year of follow-up was adopted. Results A total of 242 patients were included (PFA group: 81; CBA group: 161). Baseline characteristics were comparable between the two groups (Table 1). The PFA group was associated with shorter procedure times compared to the CBA group (64.6 ± 20.1 min vs. 80.1 ± 34.3 min, p=0.002). Complications were more frequent in the CBA group (1.2% with PFA vs. 8.1% with CBA, p=0.032), primarily due to transient phrenic nerve injury. One-year freedom from AF/AT recurrence rates were similar between the groups (91.6% for PFA vs. 93.6% for CBA; p=0.72). Conclusion In PAF patients under 50 years of age, PFA offers a safe, efficient alternative to CBA, with comparable recurrence rates, shorter procedure times, and fewer complications.