Is repeat ablation for atrial fibrillation using pulsed field energy as effective as the initial procedure? Objective evaluation using continuous monitoring

Background Pulsed field ablation (PFA) for treatment of atrial fibrillation (AF) is increasingly used for initial or repeat ablations. Repeat ablation for AF is considered to increase the chances of maintenance of sinus rhythm. There are no studies evaluating the success of repeat AF ablations with PFA using continuous monitoring. Objective To compare the long-term success of repeat vs initial PFA for AF using continuous monitoring. Methods The study enrolled patients who underwent initial or repeat PFA for AF and had continuous post ablation monitoring with an implantable loop recorder (ILR), pacemaker (PPM) or ICD systems with an atrial lead. Recurrences of AF/Flutter (Fl) after 60 days blanking period were recorded and adjudicated. Results The cohort enrolled 200 patients (age 73 ± 7 yrs, 61% males, 42% paroxysmal AF, CHA2DS2-VASc 3 ± 1) of which 58 (29%) patients underwent a repeat ablation. For these patients the initial ablation was mainly pulmonary vein isolation (PVI). Patients with repeat ablation were more likely to have persistent AF, to undergo posterior wall isolation and no PVI. (Table). No major complications occurred (no death, stroke, pericardial effusion, phrenic nerve injury), only 1 acute kidney injury (repeat ablation cohort) and 20 (10%) minor bleeding complications, similar in both groups. During a follow-up of 216 ± 133 days patients who underwent repeat ablation had higher AF/AFl recurrence 36 (62%) patients compared with 49 (35%) patients who underwent index PFA ablation. (Figure). Conclusions Our study demonstrates, using continuous monitoring that repeat PFA ablations have lower long-term success compared with first time ablation. Larger prospective studies are necessary to identify patients who benefit from repeat ablation.TableFigure