1 year clinical & safety outcome of obese patients undergoing PVI for atrial fibrillation with pulsed field or cryoballoon ablation - a prospensity matched analysis

Abstract Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia, and pulmonary vein isolation (PVI) remains the cornerstone of treatment. Thermal-based ablation techniques, such as cryoballoon ablation (CBA) and radiofrequency ablation (RFA), are widely used for PVI but show notable recurrence rates, particularly in obese patients. One possible reason for these suboptimal outcomes is the reduced efficacy of thermal energy in tissues with significant epicardial fat, which can impede effective lesion formation and insulation of targeted areas. Recently, pulsed field ablation (PFA), a non-thermal modality, has shown promise for AF treatment, providing effective isolation with a favorable safety profile. This study investigates the clinical and safety outcomes of PFA compared to CBA in obese patients with AF. Methods This retrospective propensity-matched study included symptomatic paroxysmal and persistent AF patients with a body mass index (BMI) >30 kg/m² who underwent PFA or CBA at a single institution between January 2020 and September 2024. Procedural workflows for both PFA and CBA were standardized, focusing solely on PV isolation. Post-procedural follow-up involved 72-hour Holter monitoring at 3, 6, and 12 months. Key outcomes assessed were procedural efficiency, recurrence rates, and complications. Results Pre-matching, no significant differences in 1-year recurrence rates were observed between the two methods. However, post-matching revealed lower recurrence rates in the PFA group (25%) compared to the CBA group (42.9%, p=0.02). PFA was associated with significantly shorter left atrial (LA) time (33.8 min. vs. 49.7 min., p<0.01) and procedural time (46.8 min. vs. 69.3 min., p<0.01) than CBA, although fluoroscopy time showed no significant difference. Safety outcomes were similar across both groups. Conclusion PFA offers a viable alternative to CBA in obese patients, with superior recurrence outcomes and shorter procedural durations post-matching in this single-center cohort. Both methods demonstrate comparable safety profiles. Given the procedural and clinical benefits observed, PFA may serve as a preferred approach for AF management in this high-risk population. Future randomized trials are warranted to validate these findings and optimize treatment protocols for obese AF patients.