Is addition of posterior wall isolation to pulmonary vein isolation beneficial for treatment of atrial fibrillation with pulsed field ablation? - Insights from continuous monitoring follow-up

Abstract Background The use of Pulsed Field Ablation (PFA) for treatment of atrial fibrillation (AF) is increasing. Posterior wall isolation (PWI) in addition to pulmonary vein isolation (PVI) has been advocated to improve AF ablation success with thermal energy; however, the results remain controversial. There are no studies evaluating the benefit of PWI in addition to PVI using PFA. Objective To evaluate the AF/AFl recurrences with PVI +PWI PFA and PVI PFA, using continuous monitoring. Methods The study enrolled patients who underwent PVI PFA or PVI + PWI PFA for AF and had continuous post ablation monitoring with an implantable loop recorder (ILR), pacemaker (PPM) or ICD systems with an atrial lead. Recurrences of AF/Flutter (Fl) after 60 days blanking period were recorded and reconciled. Results The cohort enrolled 142 patients (age 73 ± 7 yrs, 61% males, 47% paroxysmal AF, CHA2DS2-VASc), 83 (58%) pts underwent PVI alone and 59 (42%) PVI + PWI. In addition, 41 (29%) patients underwent typical AFl ablation, similar in both groups. The procedure time was longer in the PWI + PVI group with similar fluoroscopy time. (Table) There were no deaths, strokes, pericardial effusions, phrenic nerve injury. There were 15 (11%) minor vascular bleeding and PWI did not result in higher complication rates. During a follow-up of 235 ± 135 days there were similar, 26 (31%) and 23 (39%), AF/AFl recurrences in PVI and PVI + PWI groups, respectively. (Figure) Conclusions Our data, using continuous monitoring, show no advantage of performing PWI in addition of PVI to prevent long-term AF recurrences after PFA. However, PWI increases procedural time. Larger and randomized studies are needed to clarify if PWI has a role in treatment of AF with PFA.