Initial experience of transoesophageal echocardiography-guided percutaneous pulsed field ablation of atrial fibrillation

OBJECTIVE: Pulsed-field ablation (PFA) is a new technology of catheter ablation for atrial fibrillation (AF). This research is to investigate the feasibility of a new strategy (transoesophageal echocardiography-guided pulsed field ablation, TEEP) to guide PFA for AF with no contrast and zero fluoroscopy. METHODS: Patients with AF underwent TEEP under general anaesthesia with the guidance of three-dimensional (3D) transoesophageal echocardiography (TEE) throughout the procedure. After a successful transseptal puncture, the PFA catheter (CardiPulse) was delivered to the different pulmonary veins sequentially for standard PFA, and the pulmonary vein electrical isolation (PVI) was observed in real-time. After the ablation, left atrial bipolar voltage mapping under sinus rhythm was performed to verify the PVI. RESULTS: 10 patients with AF were enrolled, including 6 patients with paroxysmal AF and 4 patients with persistent AF. The mean operative time was 99±14 min, the mean time of the left atrial manoeuvre was 66±23 min, and the mean PFA ablation time was 105±8 s. First-pass PVI of all veins was achieved in all patients, thus no additional PFA applications were needed after the initial set. No contrast was needed and no X-ray was exposed. No complications were observed. CONCLUSIONS: We report the preliminary application of 3D TEE-guided PFA for AF in the world. Its immediate safety and efficacy are promising. Compared with traditional PFA procedures, TEEP has many advantages, including accuracy of the transeptal puncture, direct visualisation of contact between the catheter and myocardial tissue, no contrast and zero fluoroscopy.