PulseSelect pulmonary vein isolation durability at redo: reconnection sites and predictors

Background Catheter ablation is an established therapy for atrial fibrillation (AF). The PulseSelect (Medtronic) pulsed-field ablation (PFA) system offers favorable periprocedural safety; however real-world data on lesion durability and reconnection topology remain limited. Purpose To evaluate pulmonary vein (PV) reconnection rates, PV gap locations, and both procedural and anatomical predictors of PV reconnection after index AF ablation with PulseSelect. Methods We retrospectively analyzed 23 consecutive patients who underwent a clinically indicated redo ablation for atrial tachyarrhythmia recurrence after index PulseSelect PFA at our institution. A 3-D mapping system (EnSite X, Abbott) and a high-density mapping catheter (HD-Grid) were used to assess PV reconnection. PV anatomy was evaluated from pre-procedural contrast-enhanced CT. Each PV was classified as reconnected or durably isolated, and the two groups were compared by application times and anatomical characteristics (PV diameters, ostial cross-sectional area [CSA], carina width, and oriental angles). Results The mean interval between the index and redo ablation was 197 ± 65 days. PV durability was 39% per-patient and 70% per-vein, broadly consistent with past Farapulse (Boston Scientific) reports (38–45% per-patient and 71% per-vein at redo). By vein, durability was: LSPV 61%, LIPV 61%, RSPV 70%, and RIPV 83%. This pattern differed from previous Farapulse reports, where the RIPV tended to show the lowest durability (60%) and the LIPV the highest (73%). As shown in Figure, PV gaps were more frequently observed at the left anterior carina and left roof. The number of applications per vein did not differ between reconnected and isolated PVs (e.g., LSPV 12± 2 vs 12 ± 2, p = 0.68). In contrast, long-axis diameter and ostial CSA were significantly greater in LS/RS/RI PVs (e.g., LSPV long-axis diameter 28 ± 5 vs 17 ± 4 mm, p < 0.01; LSPV CSA 438 ± 146 vs 181 ± 75 mm², p < 0.01), and short-axis diameter was significantly larger across all PVs (e.g., LSPV 20 ± 4 vs 13 ± 3 mm, p < 0.01). Conclusions In redo procedures after PulseSelect PVI, overall PV durability was generally consistent with prior Farapulse data, though per-vein durability exhibited a distinct pattern. Reconnection was associated with larger PV diameter and CSA, rather than the number of applications. CT-based assessment of PV anatomy may assist in selecting the ablation system and optimize procedural strategy to improve PV durability.Distribution of PV reconnection