Procedural time predictability with pulsed field ablation compared with thermal ablation: real-world evidence in paroxysmal and persistent atrial fibrillation

Introduction Efficient use of electrophysiology (EP) laboratory resources requires accurate prediction of procedural durations for atrial fibrillation (AF) ablation. Pulsed field ablation (PFA) may optimize EP lab scheduling efficiency compared to traditional thermal methods. Purpose To quantify the impact of pentaspline PFA versus thermal ablation (radiofrequency [RF]; cryoablation [CRYO]) on procedural time predictability in real-world AF ablation and to identify clinical and procedural factors associated with time variability. Methods This is a retrospective real-world study of AF ablations performed at a single European University center. Predictability of EP lab time (patient-in to patient-out) and procedural time (skin to skin) was assessed using multiple variance tests (Levene, Brown–Forsythe, trimmed-mean). Determinants of EP lab time were identified via multivariable regression with log-transformed time as the dependent variable. Results A total of 1,845 procedures were analyzed, comprising 1,730 de novo cases (599 PFA-Pulmonary Vein Isolation [PVI], 531 PFA-PVI+Posterior Wall Isolation [PWI], 600 CRYO-PVI) and 115 redo cases (69 PFA-PVI+PWI, 46 RF-PVI+PWI). In de novo procedures, mean procedural time was 58.47±23.40 min for PFA-PVI, 71.59±31.12 min for PFA-PVI+PWI, and 75.65±39.45 min for CRYO-PVI (p<0.001) (Table 1). Similar significant differences were observed for mean EP lab time: 94.5±28.7 min for PFA-PVI, 110.1±37.2 min for PFA-PVI+PWI, and 109.3±41.7 min for CRYO-PVI (p<0.001). Across all variance tests, PFA consistently demonstrated significantly lower variability in both EP lab (p<0.001) and procedural time (p<0.001) (Figure1). Multivariable regression confirmed PFA independently reduced EP lab time compared to CRYO in de novo cases (β=–0.142, p<0.001) and with RF in redo cases (β=–0.307, p<0.001). Factors associated with longer procedural times included PWI, cavotricuspid isthmus ablation, presence of cardiac implantable electronic devices, use of 3D mapping and prior cardiac surgery. Conclusions PFA delivers more predictable procedural times than thermal ablation. Integrating procedural time predictability into ablation modality selection may enhance workflow efficiency, optimize EP lab scheduling, and improve overall procedural throughput.Table 1Figure 1