Cryoballoon vs. circular array vs. pentaspline pulsed field ablation catheter: Acute outcomes of combined roof line ablation and pulmonary vein isolation using three different ablation systems

Abstract Introduction Data on the acute outcomes of ablation techniques extending beyond pulmonary vein isolation (PVI), specifically those utilizing single-shot ablation systems, remain limited. The aim of the study was to compare the acute efficacy, feasibility, and safety of adjunctive left atrial roof line ablation using three different single-shot ablation systems in patients undergoing their first ablation for atrial fibrillation (AF). Methods and Results We enrolled 116 consecutive patients with persistent AF and left atrial (LA) dilatation (LA area: 26.1 ± 5 cm²) who underwent combined PVI and roof line ablation between November 2023 and September 2024 at our center. Patients were divided into three groups based on the ablation system used: group A (n = 62) with a cryoballoon catheter (Arctic Front Advance™); group B (n = 29) with a pentaspline catheter (Farapulse™ PFA system); and group C (n = 25) with a circular pulsed field ablation (PFA) catheter (PulseSelect™ PFA System). Efficacy Acute PVI was achieved in 100% of pulmonary veins across all groups. Fewer applications of roof line ablation were required in group A than in groups B and C (5 ± 1 vs. 11 ± 5 vs. 8 ± 4, p < 0.01). Conduction block across the left atrial roof was confirmed in 59/62 patients in group A, 29/29 in group B, and 25/25 in group C (p = 0.26). Feasibility Procedural times were longer in group A compared to groups B and C, specifically with regard to total skin-to-skin time (89.7 ± 17.8 min vs. 64.5 ± 20.6 min vs. 69.5 ± 13.1 min, p < 0.01) and LA dwell time (74.6 ± 17.8 min vs. 47.3 ± 15.8 min vs. 49.3 ± 9.8 min, p < 0.01). Fluoroscopy time was shorter in the cryoballoon group A than in the PFA groups B and C (12.6 ± 3.9 min vs. 14.7 ± 3.0 min vs. 15.5 ± 4.4 min, p < 0.01). The use of contrast medium was highest in group A (35.2 ± 11.6 ml vs. 20.6 ± 5.4 ml vs. 19.1 ± 5.6 ml, p < 0.01). Safety The complication rate did not significantly differ between the three groups (p = 0.69). Complications occurred in 3/62 patients in group A (one case of phrenic nerve palsy and two vascular complications), with no complications in groups B and C. Conclusion This study demonstrates comparable efficacy and safety profiles for the three single-shot ablation devices used in combined PVI and roof line ablation. The cryoballoon required fewer applications for roof line ablation, whereas PFA catheters were associated with shorter procedural and LA dwell times as well as reduced contrast medium usage, albeit with longer fluoroscopy times. Larger, long-term studies are warranted to further evaluate the outcomes of these ablation systems and strategies.