A personalized pulsed field ablation strategy combining PVI and algorithm-guided ablation of arrhythmogenic areas was safe and achieved an 80% one-year arrhythmia-free survival rate in patients with persistent AF.
Abstract Introduction Various strategies beyond pulmonary vein isolation (PVI) have been evaluated to improve the outcomes of persistent atrial fibrillation (AF) ablation, but no consensus has been reached on their use. Recently, an algorithm for detecting AF drivers, integrated into a 3D mapping system, has been developed to identify critical areas for ablation. Purpose We aimed to evaluate a personalized strategy combining PVI and ablation of the putative arrhythmogenic areas identified by this algorithm, using pulsed field ablation (PFA). Methods This prospective bicentric study (March 2023-April 2025) included consecutive patients undergoing a first ablation procedure for persistent AF with a 3D anatomical mapping system incorporating an AF-driver detection algorithm. All patients were in AF at the beginning of the procedure. Left atrial (LA) targets were identified by calculating local cycle length (L-CL) and the local spread of activation within that L-CL (Duty Cycle; DC) for EGMs with consistent morphology and activation. The corresponding zones were automatically highlighted on the electroanatomical map as potential arrhythmogenic areas. PVI was performed in all patients using a pentaspline PFA catheter. Extra-pulmonary vein areas identified by the algorithm were also ablated using the same PFA catheter. Follow-up included ECG and 24-hour Holter recordings at 4 and 12 months. Results Fifty patients (mean age 66 ± 11 years, 72% male) were included. Nineteen patients (38%) had AF persisting for ≥12 months, and an additional 18 patients (36%) were in AF for more than 6 months. LA dilation (≥34 ml/m2 or ≥20 cm2) was highly prevalent (n=43, 86%). Mean procedure duration was 115 ± 27 min. Sinus rhythm restoration occurred during ablation in 17 patients (34%), mostly after organization into atrial tachycardia (n = 13). The distribution of highlighted areas across LA regions varied widely between patients. PFA targeting the identified critical areas was associated with progressive AF slowing reflected by peak L-CL prolongation (171 ± 21 ms to 185 ± 25 ms, p 0.001). No major complications occurred during the procedures. At a median follow-up of 407 days, 40/50 patients (80%) were free of any atrial arrhythmia and 46/50 (92%) were free of AF. No patients whose AF terminated during ablation experienced AF recurrence. Conclusion In patients with persistent AF, a tailored PFA approach combining PVI and ablation of algorithm-guided areas was feasible, safe, and effective, achieving a high one-year arrhythmia-free survival rate. These data support an individualized substrate-guided ablation strategy beyond PVI.Distribution of highlighted areasAtrial arrhythmia-free survival
Chaumont et al. (Mon,) studied this question.