Long-term persistence of superior vena cava impact following pulsed-field ablation of the right pulmonary veins

Background Superior vena cava (SVC) conduction delay or isolation during right superior pulmonary vein (RSPV) ablation using pulsed-field ablation (PFA) has previously been described because of the anatomical proximity of the SVC to the RSPV. Purpose We aimed to evaluate the long-term effects of PFA on the SVC. Methods Among 407 consecutive patients who underwent pulmonary vein isolation (PVI) with PFA (77, Varipulse; 150, PulseSelect; 180, FARAPULSE), 18 (median age: 66 years [range, 35–77 years]; eight females) underwent a second procedure (13 for recurrent atrial tachyarrhythmias, three for follow-up catheters prior to atrial septal defect occlusion, one for atrioventricular nodal reentrant tachycardia, and one for premature ventricular contraction). In the first procedure, three, seven, and eight patients were treated with Varipulse, PulseSelect, and FARAPULSE, respectively. Right atrial mapping was performed to evaluate the acute and chronic effects of PFA on the SVC. Results In the first procedure, a low-voltage area (<0.5 mV) of ≥0.5 cm2 newly appeared in the SVC following PFA in 14 of the 18 patients (77.8%) (2/3, Varipulse; 6/7, PulseSelect; 6/8, FARAPULSE). During the second procedure, conducted after a median follow-up of 155 days (interquartile range: 97–213 days), the SVC impact persisted in 8 (57.1%) of the 14 patients (1/3, Varipulse; 3/7, PulseSelect; 4/8, FARAPULSE) (Figure; left panel). The RSPV remained isolated in four (50.0%) of the eight patients who had residual SVC impact. The distance between the RSPV and SVC was significantly shorter in patients with residual SVC impact than in those without (3.4 ± 1.1 vs. 5.4 ± 2.2 mm, p=0.024). The newly emerged low-voltage area was associated with the isthmus of atrial tachycardia in one patient (12.5%) (Figure; right panel). Conclusion RSPV isolation with PFA can affect the SVC. This effect is durable in approximately 60% of patients and may be arrhythmogenic in some cases, especially in those with shorter RSPV to SVC distances.Figure