Pulsed field ablation of atrial fibrillation in patients with reduced ejection fraction: an international, multicenter study

Abstract Background Catheter ablation of atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF) has been associated with improvement in LVEF, lower rates of heart failure (HF) hospitalizations and mortality. However, ablation procedures in this population remain technically challenging due to advanced structural heart disease and a higher comorbidity burden. Pulsed field ablation (PFA) has emerged as a promising alternative, offering shorter procedure times, no fluid overload and potentially improved safety, which may confer additional benefits in this high-risk patient cohort. Methods In an international, multicenter registry, consecutive patients with AF and reduced LVEF (≤40%) who underwent catheter ablation with PFA were enrolled. Baseline clinical characteristics, procedural parameters, and follow-up outcomes were systematically collected and analyzed. Results A total of 124 patients from four centers (82.3% male, median age 66 IQR 58-73 years; 74.2% persistent AF) were included. The most common type of cardiomyopathy was tachycardioymyopathy (39.8%) followed by ischemic cardiomyopathy (32.5%). Complete pulmonary vein isolation (PVI) was achieved in all patients using solely PFA, with a median procedure time of 40.5 (30-60) min. Additional lesions beyond PVI were performed in 27.4% of patients and median number of lesions was 40 (32-48). There were two minor complications (1.6%; access site–related) and one major complication (0.8%; transient ischemic attack). The median follow-up duration was 537 (373–763) days. At one year, recurrence-free survival was 71.4% overall, 84.7% in paroxysmal AF, and 67.4% in persistent AF (p = 0.184). Median LVEF at baseline was 30.5% (25–36). In patients who remained in stable sinus rhythm during follow-up, LVEF improved to 50% (40–60; p 0.001), whereas in patients with AF recurrence, LVEF was 40% (33–45; p 0.001). The mean number of cardiology-related hospitalizations decreased from 1.04 ± 0.9 in the year prior to ablation to 0.36 ± 0.7 in the year after ablation (p 0.001). Conclusion In patients with reduced ejection fraction, pulsed field ablation (PFA) demonstrated high efficacy, short procedure times, a low complication rate, and favorable long-term arrhythmia-free survival. Moreover, a significant improvement in left ventricular ejection fraction and a reduction in hospitalizations were observed during follow-up.