Timing and incidence of symptomatic early recurrence following pulmonary vein isolation with pulsed-field compared with radiofrequency ablation.

BACKGROUND

Early recurrence of atrial tachyarrhythmias (ERAT) is common after pulmonary vein isolation (PVI) and is traditionally attributed to transient post-procedural inflammation. With the introduction of pulsed field ablation (PFA), the incidence and prognostic significance of ERAT compared with thermal ablation remains unknown.

OBJECTIVE

The study aimed to compare the incidence of ERAT during the blanking period in patients undergoing PFA versus radiofrequency (RF) ablation for atrial fibrillation (AF).

METHODS

We prospectively enrolled patients undergoing first-time PVI between 2022 and 2025 at our institution. Propensity score matching was performed to address baseline imbalances and group size differences between RF and PFA PVI. The incidence of ERAT and its association with 9-month arrhythmia recurrence, defined as late recurrence of atrial tachyarrhythmias (LRAT), were analyzed.

RESULTS

A total of 962 patients were included (420 RF, 542 PFA). Patients with ERAT were more likely to be older, have persistent AF, higher CHA2DS2-VASc scores, larger atria, reduced ejection fraction, and no prior antiarrhythmic drug use. After multivariable adjustment, PFA was independently associated with a lower risk of ERAT compared with RF (hazard ratio [HR] 0.61; 95% confidence interval 0.42-0.88). ERAT was strongly associated with LRAT, with a 3-4-fold higher risk of atrial arrhythmias at 9 months (early ERAT: HR 3.78, P < .001; late ERAT: HR 4.10, P = .001), regardless of ablation modality.

CONCLUSION

PFA is associated with a significantly lower risk of ERAT compared with RF ablation. The occurrence of ERAT, irrespective of energy source, predicts a substantially higher risk of LRAT.