Optimizing Pulsed Field Ablation: Results From a 1,000-Patient Cohort.

BACKGROUND

Pulsed field ablation (PFA) using the pentaspline catheter is a nonthermal technology for pulmonary vein isolation (PVI) in atrial fibrillation (AF). We progressively refined the procedural workflow to enhance safety, PVI durability and long-term outcomes, including the transition from 8 applications to the 10-application "olive" strategy.

OBJECTIVES

This study aimed to evaluate procedural characteristics and long-term outcomes and to assess the impact of sequential workflow refinements.

METHODS

This single-center study included consecutive AF patients undergoing PVI using the pentaspline PFA catheter between April 2021 and May 2024, excluding ablation beyond PVI. Procedural data and follow-up outcomes were collected and analyzed.

RESULTS

In total, 1,000 patients (median age 69 years [Q1-Q3: 60-76 years]) were included and PVI was achieved in all patients with a median procedure time of 30 minutes (Q1-Q3: 25-40 minutes). The major complication rate was 0.5% (total 2.1%; primarily access site related). Median follow-up time was 454 days (Q1-Q3: 370-631 days). One-year arrhythmia-free survival was 76.6%, higher in paroxysmal AF (83.8%) vs persistent AF (66.6%) (P < 0.001). Durable PVI was observed in 82% (n = 562 of 685) of veins across 173 repeat procedures. Workflow refinements improved safety, including a trend toward reduction of tamponades from 0.8% (n = 2 of 260) to 0% (n = 0 of 740) (P = 0.067), and procedure-related bradycardia from 49.3% to 5% (P < 0.001). Furthermore, PVI durability increased from 78.7% with the conventional approach to 91.6% (P < 0.001) with the olive strategy, while long-term outcomes remained unchanged.

CONCLUSIONS

In this large cohort, PFA demonstrated high efficacy with short procedure times, low complication rates, and favorable long-term outcomes. Workflow refinements improved safety and PVI durability, underscoring PFA's role for standardized and safe AF ablation.