Pulsed-field- vs. cryo- vs. radiofrequency ablation: one-year recurrence rates after pulmonary vein isolation in patients with persistent atrial fibrillation

Funding Acknowledgements Type of funding sources: None. Background A multipolar pulsed-field ablation (PFA) catheter has recently been introduced and showed favorable data in terms of safety and procedural efficiency of pulmonary vein isolation (PVI) for atrial fibrillation (AF). Long-term outcome data in comparison to other ablation modalities however is lacking. Purpose To compare procedural and one-year recurrence data of patients with persistent AF (persAF) undergoing a first PVI using PFA, cryoballoon ablation (Cryo), or radiofrequency (RFA). Methods Consecutive patients with persAF undergoing a first PVI with PFA at our institution from May to December 2021 were included. For comparison, patients with persAF undergoing a first PVI with Cryo or RFA between May 2020 and March 2021 were included. A 3-D electro-anatomical mapping system was used in PFA and RFA, but not in Cryo. The following ablation protocols were used to achieve acute PVI: In the PFA group, the standard 32-applications lesion-set and supplementary applications at the discretion of the operator. In the Cryo group, a time-to-effect plus two minutes strategy and in the RFA group following to the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of any atrial arrhythmia following a blanking period of 3 months. Results A total of 177 patients were included (PFA: 65; Cryo: 63; RF: 49). Age, gender, CHA2DS2-VASc score, LVEF and LAVI did not differ among the groups (Table). Median procedure time was different among the groups (PFA: 109 [interquartile range 88-130] min, Cryo: 81 [62-96] min, RF: 177 [153-200] min, p < 0.01). Fluoroscopy dose was different among groups: RF (1.9 [0.7-4.9] Gycm2), PFA (8.3 [4.3-19.0] Gycm2), and Cryo (9.5 [4.8-19.1] Gycm2, p<0.01). Median follow-up time in patients without recurrence was 13 [11-13] months for the PFA group, 13 [12-13] months for the Cryo group and 12 [11-13] months for RFA group. Recurrence of atrial arrhythmias in the KM-analysis after 12 months was not different in all three groups (PFA 44%, Cryo: 33%, RFA: 51%, Figure). Conclusion In patients with persAF, recurrence of atrial arrhythmias 12 months after PFA-PVI only is high, regardless of ablation modality. Assessment of strategies including ablation of extra-PV targets in some patients with persAF is needed.