Pulsed field ablation for pulmonary vein isolation with or without posterior wall ablation in patients with persistent atrial fibrillation: a multicenter study.

BACKGROUND

Posterior wall ablation (PWA) is frequently performed during pulsed field ablation (PFA) of persistent atrial fibrillation (pe-AF), despite unclear evidence. We aim to study the safety and efficacy of PWA, compared to pulmonary vein isolation (PVI) alone, in this population.

METHODS

In this multi-center study, we included all patients with pe-AF who underwent PFA from April to November, 2024. Clinical records were retrospectively reviewed for demographics, procedural details, and clinical outcomes.

RESULTS

During the study period, 387 patients with pe-AF underwent PFA (mean age 68.7 years, 32.0% female, 80.1% PWA). At a mean (standard error of the mean) follow-up of 12.1 (0.3) months, arrhythmia recurrence was 19.5% for PVI and 26.8% for PVI + PWA (p = 0.19). In multivariable Cox proportional hazards models, PWA was not independently associated with arrhythmia recurrence (adjusted hazard ratio [aHR] 1.36; 95% confidence interval [CI] 0.77-2.39) or with pe-AF recurrence requiring additional rhythm control strategies (aHR 1.08; 95% CI 0.57-2.05). Of the recurrences after PWA, 25.3% were with atrial flutter/tachycardia (AFL/AT). In a time-varying Cox analysis, there was evidence of treatment-effect non-proportionality (p = 0.02). PWA was not associated with recurrence 90-190 days post-ablation (aHR 0.78; 95% CI 0.40-1.53), but was associated with higher recurrence hazard thereafter (aHR 3.13; 95% CI 1.10-8.87).

CONCLUSIONS

PWA was not associated with atrial arrhythmia recurrence in patients with pe-AF. More recurrences in the form of AFL/AT, in combination with a late increase in recurrence hazard, may be indicative of a potential for re-entry after PWA.