Midterm outcomes of staged hybrid convergent procedure versus PVI and PW pulsed field ablation in long standing persistent AF patients

Abstract Background There are limited effective treatment options for persistent atrial fibrillation (AF) patients, with pulmonary veins (PV) isolation alone being considered suboptimal for many patients. Hybrid convergent ablation has been shown to improve clinical outcomes when compared to an endocardial-only radiofrequency (RF) strategy. Pulsed field ablation (PFA) has recently gained growing interest for its efficacy and safety profile in PV and posterior wall (PW) ablation. Objectives This study aimed to compare the efficacy and safety of the hybrid-convergent RF vs PFA of PVs and LAPW in long-standing persistent atrial fibrillation (LSPAF) Methods Ninety-three consecutive LSPAF patients, treated with 2-step hybrid-convergent RF ablation (hybrid group, n = 49) or with PFA of PVs and LAPW (PFA group, n = 44) were enrolled. Primary efficacy endpoint was defined as any atrial tachyarrhythmias (ATA) recurrence after the 3-month blanking period, over a follow-up time of 18 months. Periprocedural adverse events and late complications during follow-up were deemed primary safety outcomes. Results PV and LAPW ablation were acutely successful in all patients. The hybrid and PFA groups had similar baseline characteristics: no differences were found between PFA and Hybrid groups regarding age (PFA 66.0±7.4 years vs Hybrid 63.9±10.6 years; p=0.193) and left atrial volume index (PFA 45.5 [36.7-57.2] ml/m2 vs Hybrid 45.0 [39.2-59.7] ml/m2; p=0.920). There were no significant differences regarding AF duration (PFA 38.0 months [IQR: 19.2 to 99.0 months] vs Hybrid 70.0 months [IQR: 46.0 to 118.0 months]; p = 0.063). Redo ablation patients’ rate was higher in the hybrid group (PFA n=16, 36.4% vs Hybrid n=28, 66.6%; p<0.001). Differences regarding left ventricular ejection fraction were borderline significant among groups (PFA 55.0 [49.5- 62.0] % vs Hybrid 60.5 [52.3-65.0] %; p=0.048), both showing an overall normal LV function. Step 1 hybrid-epicardial procedures were longer than PFA (166 [Q1-Q3: 140-205] minutes vs 107.5 [Q1-Q3: 82.5-12] minutes; P < 0.01). After a median follow-up of 615.5 [498–750] days, there was no difference in ATA recurrences between groups (Hybrid 52,3 % vs PFA 44,1 %; P = 0.450); no difference in the antiarrhythmic drug use rate was found (PFA n=24, 54.5% vs Hybrid n=19, 45.2%; p=0.388). PFA showed a better safety profile with a lower rate of major periprocedural complications compared with hybrid ablation (12% vs 0%; P = 0.028). Conclusions Hybrid-convergent and PFA PVI and PW ablation share 18 months comparable arrhythmic outcomes in LSPAF, with PFA of PV and PW being an endocardial-only, less invasive and faster procedure.