Pulmonary vein isolation using a novel balloon-in-basket pulsed field ablation system: The Lübeck how-to protocol.

BACKGROUND

Single-shot pulsed field ablation (PFA) is increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). Although balloon-in-basket (BiB)-PFA system integrates ablation and mapping into a single catheter, standardized procedural workflows remain limited.

OBJECTIVE

This study aimed to describe a standardized, step-by-step workflow for AF ablation using the BiB-PFA system and evaluate procedural performance, acute safety, and the learning curve in clinical practice.

METHODS

This prospective, single-center study included 40 consecutive patients undergoing index PVI using the BiB-PFA system at a tertiary high-volume electrophysiology center. Procedures followed standardized protocol including balloon preparation, ultrasound-guided access, fluoroscopy-guided transseptal puncture, selective pulmonary vein (PV) angiography, and a structured 2-step ablation approach for each vein. Posterior wall ablation (PWA) was performed in selected patients. Procedural metrics and acute complications were analyzed descriptively.

RESULTS

Patients were 64.5 years old (56.5, 73.3); 41% were female, and 57.5% had nonparoxysmal AF. The median procedural duration was 41.5 minutes (35.0, 59.0), left atrial dwell time 27.5 minutes (25.0, 36.0), and BiB dwell time 23.0 minutes (20.0, 25.8). A median of 4 applications per PV was used. Reduced-energy delivery was required in 30% of right inferior and 25% of right superior PV. PWA was performed in 35% of patients using a median of 5 applications. No major intraprocedural complication occurred. The mean procedural duration decreased from 50.0 minutes (38.0, 60.5) in the first 10 cases to 34.5 minutes (31.5, 52.0) in the last 10 cases (P = .059).

CONCLUSION

A standardized BiB-PFA workflow enables efficient, safe, and reproducible PVI with optional PWA and can be rapidly implemented during early operator experience.