Optimized Workflow for Pentaspline PFA and Its Impact on PVI Durability: Evidence From Systematic Remapping

INTRODUCTION: Real-world series report substantial rates of pulmonary vein (PV) reconnection following index procedure with a pentaspline pulsed-field ablation (P-PFA) catheter. The contrast with initial durability data suggests this may be due to limitations in procedural workflow. METHODS: We conducted a single-centre, prospective study including consecutive patients undergoing first-time P-PFA pulmonary vein isolation (PVI), subsequently scheduled for systematic invasive remapping ≥30 days after the index procedure. Workflow was progressively refined in three phases, aiming at ensuring adequate tissue contact and based on previous remapping findings. The primary endpoint was PVI durability, per vein and per patient. RESULTS: Of 118 enrolled patients, 94 (phase 1:n=30; phase 2:n=34; phase 3:n=30) underwent systematic remapping, where 13, 10, and 1 reconnected PVs were observed in phases 1, 2 and 3, respectively. This resulted in per-vein durability of 89.8%, 92.9%, and 99.2% (p=0.005) and per-patient durability of 60.0%, 76.5%, and 96.7% (p=0.004). Mean total PFA applications increased from 36.8±5.2 in phase 1 to 52.1±8.0 and 58.7±15.1 in phases 2 and 3, respectively (p<0.001). Median procedure time rose from 43 (39-50) minutes in phase 1 to 46 (42-56) minutes in phase 2 and 69 (61-77) minutes in phase 3 (p<0.001), with significant parallel increases in LA dwell time (p<0.001) across phases. No major or minor complications occurred during index or remapping procedures. CONCLUSION: Progressive workflow refinements for pentaspline P-PFA markedly improved PVI durability to nearly 100%, supporting the concept that PV reconnection is predominantly technique-dependent rather than intrinsic to catheter or waveform design.