Safety and acute efficacy of atrial fibrillation ablation using a pentaspline pulsed field ablation catheter in patients with severely reduced ejection fraction: results from the FRANCE-PFA registry

Introduction Data are scarce regarding the safety and acute efficacy of atrial fibrillation (AF) ablation using a pentaspline pulsed field ablation (PFA) catheter in patients with severely reduced left ventricular ejection fraction (LVEF) < 30%, a population often considered at high procedural risk. Purpose To evaluate procedural characteristics, acute efficacy, and safety outcomes of PFA in patients with an LVEF < 30% undergoing first-time AF ablation. Methods This was a subanalysis of the FRANCE-PFA prospective nationwide registry, which included all patients undergoing a first AF ablation using the pentaspline PFA catheter between March 2021 and February 2024 in 33 French centers. All patients with a baseline LVEF < 30% were included in this subanalysis. Results A total of 134 patients with LVEF < 30% were included (mean age 63.4 ± 10.8 years; 17.9% women; BMI 28.7 ± 5.4 kg/m²; CHA2DS2-VA score 2.9 ± 1.4). AF type was paroxysmal in 37 patients (27.6%), persistent in 85 (63.4%), and long-standing persistent in 12 (9.0%). A nonischemic dilated cardiomyopathy was present in 48.1%, an ischemic cardiomyopathy in 32.7%, and a suspected arrhythmia-induced cardiomyopathy in 19.2%. Severe left atrial dilation was observed in 44.3% of patients, moderate in 24.1%, and none in 25.3%. The majority of procedures were performed under general anesthesia (123; 91.8%) and the remaining 11 procedures (8.2%) were performed under deep sedation (with spontaneous ventilation). The mean procedure duration was 58.0 ± 22.9 minutes and fluoroscopy time was 15.6 ± 9.4 minutes. Acute pulmonary vein isolation (PVI) was achieved in all patients. PVI only was performed in 68 patients (50.7%). Additional PFA lesion sets included the left atrial (LA) posterior wall in 49 (36.6%), the LA roof in 39 (29.1%), the mitral isthmus in 20 (14.9%), and the cavotricuspid isthmus in 8 (6.0%). Two major complications occurred (1.5%): one cardiac tamponade and one ventricular tachycardia that occurred in a patient with stable coronary artery disease during PFA application on the LA posterior wall. No esophageal injury or symptomatic phrenic nerve palsy was observed at discharge. Fifty-two patients (38.8%) were discharged on amiodarone. Conclusions In this prospective nationwide registry, PFA in patients with severely reduced LVEF appeared safe and acutely effective, with a low complication rate. These findings suggest that PFA may be a suitable ablation strategy even in patients with severe left ventricular dysfunction.