Pulmonary vein reconduction after pentaspline pulsed field ablation: patterns and predictors from a nationwide cohort

Background Pulsed field ablation (PFA) is increasingly used for pulmonary vein (PV) isolation in atrial fibrillation (AF), but data on PV durability remain limited. Objective We evaluated PV reconduction during repeat ablation and factors associated with reconduction in a nationwide cohort. Methods We retrospectively included consecutive Danish patients undergoing first-time PVI using a pentaspline PFA catheter between July 2021 and January 2024. All PVs were successfully isolated during the index procedure. Patients were followed for ≥12 months. Arrhythmia recurrence was identified from ECGs, ambulatory monitoring, or wearable devices. PV reconduction was assessed during clinically indicated repeat ablation. Results Among 1,269 patients (median age 64 [56–70] years; 65% male; 48% persistent AF), 419 (33%) experienced recurrent atrial tachyarrhythmia during follow-up of 21 [17–26] months. Repeat ablation was performed in 188 patients, including PV remapping in 185. At repeat ablation, 131 patients (71%) demonstrated reconduction in ≥1 PV, whereas 54 (29%) had durable PVI. Reconduction most frequently involved the right-sided PVs. In multivariable analyses, male sex was independently associated with PV reconduction, whereas preprocedural CT was associated with lower odds of reconduction. AF recurrence predominated in patients with PV reconduction, whereas atrial flutter and atrial tachycardias were more common in patients with durable PVI. Conclusion In this nationwide real-world cohort, PV reconduction after first-time pentaspline PFA was common and predominantly involved right-sided PVs. Recurrence phenotype differed according to PV durability. The observed associations between male sex, preprocedural CT imaging, and PV reconduction are hypothesis-generating and require prospective validation.