Pulsed field atrial fibrillation ablation with a focal tip dual energy contact force-sensing catheter under local anesthesia: anatomical and clinical correlation

Background Pulsed field ablation (PFA) has demonstrated high efficacy and safety for pulmonary vein isolation (PVI). So far single-shot and large footprint devices have been used mainly under general anesthesia to avoid muscle contraction. Recently a focal tip contact force-sensing catheter toggling between radiofrequency (RF) and PF became available and its design may cause less neuro-muscular recruitment. Purpose We aimed to investigate the tolerability of PF delivered through this catheter for AF ablation under local anesthesia. Methods All consecutive patients undergoing de novo ablation for persistent AF under local anesthesia with a dual energy contact force-sensing catheter were enrolled in the study. PF was used posteriorly for PVI and floor line. All symptoms along with the specific site they occurred were noted during PF ablation. On the ECG-gated CT-scan performed before the procedure the position of the oesophagus was recorded and the shortest distance between the PV ostia and the closest ipsilateral bronchus was measured offline blinded to symptom status. The rate of first pass and final PVI and floor line block as well as the occurrence of acute complications were recorded. Results 24 consecutive patients (age 67±9 years, male 79%) were enrolled. No muscular contraction was observed during PF applications. 18 (64%) experienced cough during the procedure (54% during left superior vein ablation). Patients experiencing cough at the left and right superior pulmonary vein had a shorter average distance between the bronchus and the corresponding PV ostium (11±4 mm vs 17±5 mm, p=0.004 and 20±3 mm vs 24±4 mm, p=0.05) whereas no significant difference was found for the left and right inferior PVs (13±3 mm vs 16±5 mm and 19±7 mm vs 22±7 mm respectively, all p=ns). The PF index was similar in patients with and without cough except at the right inferior PV (414 vs 469 respectively, p=0.027). 18 (64%) experienced pain (50% during left inferior vein ablation). No significant association was found between the site of pain and the position of the oesophagus on CT scan The PF index at the different sites was similar in patients with and without pain (all p=ns). A switch from PF to RF (3±2 applications) for cough or pain was necessary in 9 (37%) at the LSPV, 1 (4%) at the LIPV, 3 (12%) at the RSPV, 2 (8%) at the RIPV and 1 (4%) at the floor. Total procedure, LA dwell time and fluoroscopy time were similar in patients with and without symptoms. PVI was achieved in 100% and dome block in 89% without significant differences according to the presence of pain and cough. No complications were reported acutely. Conclusions PFA at the posterior left atrium to perform PVI and floor line with a focal dual-energy contact force-sensing catheter is feasible and safe under local anesthesia. While muscular contraction was not observed, cough and pain are common, especially during left vein ablation, but without affecting efficacy or procedure time.