The role of pulmonary vein anatomy in predicting atrial arrhythmia recurrence after pulsed-field ablation

Background Pulmonary vein isolation (PVI) using pulsed-field ablation (PFA) has comparable atrial arrhythmia (AA) recurrence rates compared to thermal energies. The impact of left atrial anatomy on long-term AA recurrence after PFA-based PVI is unknown. Purpose To assess left atrial anatomical features that may predict AA recurrence after PFA-based PVI. Methods We prospectively enrolled patients undergoing PFA-based PVI with a pentaspline catheter at a tertiary center from June 2023 to September 2024. Follow-up included clinical visits with a Holter-ECG at 3, 6 and 12 months after the procedure to assess AA recurrence. We measured pulmonary vein ostial diameter (maximum and minimum, measured orthogonally), intercarina distances and size of the left lateral ridge in preprocedural three-dimensional CT and MRI left atrial reconstructions. Additionally, PV ovality was calculated based on PV ostium dimensions. Univariate logistic regression models were used to assess the impact of these anatomical features on AA recurrence with additional sub-analysis for the 31 and 35 mm pentaspline catheter. Results Out of 90 patients (median age 72 [33 - 88] years, 33% female, 35% paroxysmal atrial fibrillation), 16 (18%) experienced an AA recurrence after a median follow up of 101 days. In regression analysis, the maximum (OR: 1.25; [95% CI: 1.04-1.50]; p = 0.019) and minimum (OR: 1.19; [95% CI: 1.01-1.40]; p = 0.039) diameters of the right superior pulmonary vein were significant predictors of AA recurrence. This association was only significant in patients treated with the 31mm diameter catheter (OR: 1.78; [95% CI: 1.13-2.81]; p = 0.013), but not with the 35 mm catheter (OR: 1.10; [95% CI: 0.89 – 1.35]; p = 0.384. No other anatomical feature was significantly associated with AA recurrence. Conclusion The right superior pulmonary vein diameter was an anatomical predictor of AA recurrence after PFA-based PVI. This association was only found with the 31 mm, but not the 35 mm pentaspline catheter. Our findings suggest an individualized approach for PFA-based PVI based on left atrial anatomy.