Extensive vs. limited pulmonary vein isolation in pulsed field ablation using a circular over-the-wire catheter

Background While previous studies with the PulseSelect (PS) circular over-the-wire catheter show good short-term efficacy and safety in pulmonary vein isolation (PVI) for atrial fibrillation (AF), long-term results in everyday clinical practice are still limited. With substantial arrhythmia recurrence, and pulmonary vein (PV) reconnection during repeat ablation, we believe that more applications are needed to improve lesion durability. Objective This study compares 4 ostial + 4 antral to 4 ostial + 8 antral applications for antral wide PV ablation in terms of isolation durability, efficacy, and safety. Methods Single-center registry of patients with paroxysmal or non-paroxysmal AF undergoing primary PVI using the PS PFA system in the Netherlands from March 24 to September 5, 2025. According to local protocol, patients treated before 20 Jun 2025 received at least 8 applications per vein (8-applications group), after which date the protocol was changed to a minimum of 12 applications per vein (12-applications group). Endpoints included acute isolation of ablation targets, adverse events, and AF recurrence after a 2-month blanking period. Recurrence was monitored via event-driven photoplethysmography or electrocardiograms and analyzed with Kaplan-Meier curves and log-rank tests. Results This analysis included 115 patients, of which most were male (65,9%), mean age of 64 years, paroxysmal AF in 80 patients (69.6%). A total of 75 patients were included in the 8-applications group, versus 40 in the 12 applications group. All procedures were PVI-only. Patients in the 12-applications group had a higher total number of applications (48.0 [48.0, 50.0] vs 34.0 [32.0, 35.0]), longer procedure duration (42.5 vs 36.0 min, P<0.001) and fluoroscopy time (13.0 vs 10.0 min, P<0.001). Acute procedural efficacy was 100% vs 97.3% in the 12- vs 8-application groups. Complications included two minor and one major vascular event in the 8-application group, with no other complications observed. During follow-up arrhythmia recurrence did not significantly differ (log-rank P=0.78), although there was a non-significant trend toward higher short-term AF freedom in the 12-application group. Conclusion In this small preliminary cohort, 12 versus 8 applications per pulmonary vein showed similar acute efficacy and complication rates, with a non-significant trend toward higher short-term freedom from atrial fibrillation in the 12-application group. Follow-up is limited, but by April 2026 longer follow-up and more patients will allow a more robust analysis of the 12 application approach.