Role of 3D-electro-anatomical mapping on procedural characteristics and outcomes in pulsed-field ablation for atrial fibrillation

Introduction While the utilization of dedicated 3D-electro-anatomical mapping (EAM) systems for catheter ablation of atrial fibrillation (AF) is crucial using radiofrequency, its potential benefits in pulsed-field ablation (PFA) remain uncertain. This is of particular interest, since some PFA ablation systems will soon be available with integrated 3D-EAM capabilities. Objectives To compare the procedural characteristics and outcomes of patients undergoing PFA for pulmonary vein isolation (PVI) with mapping and with no mapping. Methods We prospectively enrolled patients undergoing their first PVI at a tertary referral center. In patients undergoing PVI with mapping, a multipolar mapping catheter was used to create voltage maps during sinus rhythm pre- and post-ablation. In the non-mapping group PVI was confirmed by assessing entrance block via the PFA catheter. The first 30 cases with mapping were excluded to account for a potential learning curve. Results A total of 197 consecutive patients were included (age 65 [interquartile range (IQR) 58 – 72] years; indexed left atrial volume 40 [IQR 35 – 44] mL/m2). Among these, 127 patients (64%) underwent PVI with mapping and 70 patients (36%) with no mapping. The median procedure duration, left atrial dwell time and the fluoroscopic time for the mapping vs the non-mapping group were 55 [IQR 45 – 67] min vs. 28 [IQR 23 – 35] min (p < 0.001), 38 [IQR 30 – 49] min vs. 15 [IQR 11 – 21] min (p < 0.001), 11 [IQR 9 – 14] min vs. 8 [IQR 7 – 11] min (p < 0.001), respectively. In the mapping group in 9% (11/127 patients) at least 1 PV was incompletely isolated and required additional applications. Acute PVI success was 100%. There were two complications in the mapping group (one stroke, one coronary artery air embolism) and none were observed in the non-mapping group. The recurrence rate of atrial arrythmias during a median follow-up of 267 [IQR 164 – 419] days was 14% in the mapping group and 17% in the non-mapping group, p = 0.728. Conclusion In conclusion, the use of PFA with no mapping was associated with a significant decrease in procedural characteristics, while AF-recurrence was not significantly different. The routine use of mapping for PFA-PVI may not be needed.