Pulsed‐Electrical Field Ablation Completes Pulsed‐Field Ablation—Lessons Learned on Tissue Proximity Indication in Pulmonary Vein Isolation

INTRODUCTION: Pulmonary vein isolation (PVI) in atrial fibrillation (AF) is the current cornerstone for AF ablation. Besides thermal ablation techniques, nonthermal pulsed-field ablation (PFA) is rapidly transforming the way PVI is achieved. As every new technology has its own learning curve, we would like to report the lessons we learned by treating a 63-year-old woman admitted for paroxysmal AF ablation, with symptomatic palpitations. METHODS AND RESULTS: We initially performed PVI with a pulsed-electrical field variable-loop circular catheter with the CARTO 3 mapping system. When the patient experienced recurrence of AF even after 3 months, the scheduled reablation procedure showed a reconnection of both posterior carinae. When revisiting the initial map, both recurrences occurred at the points where tissue proximity indication (TPI) during ablation was likely not sufficient, leading to reversible electroporation and subsequent reconnection of the veins. Those remaining areas were again ablated using PFA energy with a linear ablation catheter. CONCLUSION: TPI-based contact filtering for transmural lesion success and durability seems to be a relevant tool to ensure irreversible electroporation and is likely of prognostic relevance.