Left atrial anatomy and atrial arrhythmia recurrence after pulsed-field ablation

Background The impact of left atrial (LA) anatomical features on atrial arrhythmia (AA) recurrence after pulsed-field (PF)-based pulmonary vein isolation (PVI) is unknown. This study aimed to assess LA anatomical features associated with long-term AA recurrence after PVI. Methods We prospectively enrolled patients undergoing PVI with a pentaspline PF-catheter at a tertiary center from June 2023 to September 2024. AA recurrence was assessed at 3, 6 and 12 months with Holter-ECGs and symptom-driven monitoring. The following anatomical features were assessed in pre-interventional CT or MR imaging: pulmonary vein (PV) ostial diameters, circularity, cross-sectional area, and inter-carina distances. Regression models adjusted for established risk factors were used for their associations with AA recurrence. Results Among 287 patients (median age 66 years; 34% female; 61% paroxysmal AF), 98 (34%) experienced recurrence at a median of 6 months after PVI. In adjusted regression analysis, a larger minimal diameter of the right superior PV (OR 1.11 per 1 mm increase, 95% CI (1.02–1.21); p = 0.021), and higher circularity indices of the left inferior PV (OR 1.04 per 0.01 increase, 95% CI (1.01–1.07); p = 0.005) and the right superior PV (OR 1.03 per 0.01 increase, 95% CI (1.00–1.06); p = 0.040) were associated with AA recurrence. There was no interaction for catheter size but some effect modification for the number of PF-applications. Conclusion Specific anatomical features of the right superior and left inferior PV were associated with recurrence after PF-based PVI. Although PF-based PVI appears suitable across diverse LA anatomies, the prognostic value of these anatomical characteristics warrants further investigation.