Single-center experience of an image-guided single-access, single-catheter pulsed field ablation approach for pulmonary vein isolation

Background Conventional pulmonary vein isolation (PVI) with thermal energy often requires multiple catheters and venous punctures and carries vascular and collateral risks. Pulsed field ablation (PFA) may enable a simpler approach; further streamlining of PFA workflows could be feasible without increasing procedural risk and may shorten hospital stay. Objective This single-center study aimed to describe a streamlined, image-guided, single-access, single-catheter PVI approach enabled by PFA to reduce procedural complexity while maintaining effective PVI. Methods In this retrospective single-center study, 191 (mean age 67±10 years old, 35% female) consecutive patients undergoing first-time PVI for atrial fibrillation via a single femoral venous access. A single-shot PFA strategy with a biphasic, bipolar waveform was employed using either a pentaspline catheter (FP group; n=124 [64.9%]) or a circular multielectrode catheter (PS group; n=67 [35.1%]). A pre-acquired contrast-enhanced cardiac CT was reconstructed as a 3D model and integrated with fluoroscopy for procedural guidance. After a single venous puncture, a diagnostic catheter was advanced to mark the His position, and a guidewire was positioned in the caval veins to define SVC/IVC landmarks on the fused CT–fluoro roadmap. The diagnostic catheter was then removed, and a single long steerable sheath was used for transseptal access and PFA catheter delivery (FP or PS). Baseline characteristics were comparable between groups. Results Acute isolation of all pulmonary veins was achieved in all patients. Mean procedure duration was 60±14 minutes (57.7±11.8 minutes in FP group and 64.1±16.6 minutes in PS group); fluoroscopy time 6.8±3.5 minutes (6.2±2.2 minutes in FP group and 7.9±2.2 minutes in PS group) and radiation exposure 98±75 cGy/cm2 (88±52.9 cGy/cm2 with FP and 115,7±104 cGy/cm2 with PS) were low and consistent with contemporary PFA data1,2. Transient phrenic nerve palsy occurred in 22 (11.5%) patients, with complete recovery in all during the hospital stay. Major complications were rare: 1 transient respiratory insufficiency, 1 transient ischemic attack, and 2 groin hematomas. No pericardial effusion/tamponade or other relevant complications were observed. Conclusion An integrated CT-guided, single-access, single-catheter PFA strategy for PVI is feasible, achieves 100% acute PVI, and is associated with a low complication rate, supporting this simplified approach as an attractive alternative to conventional multi-catheter thermal ablation workflows.transeptal punctureimage-guided procedure