Impact of per-procedural AF termination on recurrence after pulsed field ablation of persistent atrial fibrillation

Background Achieving per-procedural termination of atrial fibrillation (AF) during ablation is thought to indicate effective substrate modification and predict better outcomes. However, AF termination may rather reflect a less remodeled atrial substrate than a procedural endpoint to pursue. We evaluated recurrence-free survival according to per-procedural AF termination in patients undergoing pulsed field ablation (PFA) with a standardized PVI + posterior wall + mitral isthmus lesion set. Methods 234 consecutive patients undergoing PFA for persistent AF with complete PVI + posterior wall + mitral isthmus ablation were retrospectively analyzed. Time-to-recurrence was measured from procedure to first documented AF recurrence; patients without recurrence were censored at last follow-up. Kaplan–Meier curves compared recurrence-free survival between patients with and without per-procedural AF termination. Analyses were censored at 24 and 15 months; group differences were assessed with the log-rank test. Results Among the 234 patients, recurrence-free survival was higher in patients with AF termination (log-rank p = 0.0019 at 24 months; p = 0.0053 at 15 months). Within 15 months, recurrences occurred in 11/110 (10.0%) versus 28/124 (22.6%) without AF termination. Left atrial size tended to be smaller in patients with termination: echocardiographic LA volume index 47 vs 42 mL/m² (OR 1.38 [0.90–2.43]; p = 0.058), and CT LA diameter 44 vs 46 mm (OR 0.95 [0.75–1.19]; p = 0.33), though not statistically significant. Conclusions During standardized PFA with PVI + posterior wall + mitral isthmus ablation, per-procedural AF termination was associated with improved recurrence-free survival and a trend toward smaller left atria, suggesting it reflects a less remodeled atrial substrate rather than a procedural endpoint.