Pulmonary Vein Isolation Alone Versus Adjunctive Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND: Pulmonary vein isolation (PVI) is the standard ablation strategy for paroxysmal atrial fibrillation (PAF). Despite guideline recommendations favoring PVI alone in PAF, some operators routinely perform extra pulmonary vein ablation (PVI+) during initial procedures. OBJECTIVE: To determine frequency of PVI+ strategy for treatment of PAF in the real world and examine its impact on arrhythmic recurrence and progression compared to PVI alone. METHODS: Using the TriNetX research network, we identified adults with PAF who underwent catheter ablation between January 2020 and January 2024. Recurrence was defined as repeat ablation, cardioversion, or antiarrhythmic drug (AAD) use beyond a 3-month blanking period. Progression to persistent AF and atypical atrial flutter were also assessed. Kaplan-Meier analysis was performed with 3-year follow-up. RESULTS: Before matching, 5134 of 18,891 patients (27.2%) underwent PVI+. In the propensity matched analysis (n = 5020 per group), recurrence was significantly higher in the PVI+ group (HR 1.28, 95% CI 1.16-1.42; p < 0.001). Repeat ablation, cardioversion and AAD use were more common with PVI+ (HR 1.99, 95% CI 1.60-2.46; p < 0.0001, HR 1.37, 95% CI 1.13-1.66; p = 0.001, and HR 1.41, 95% CI 1.05-1.87; p = 0.020, respectively). Progression to persistent AF was higher with PVI+ (HR 1.37, 95% CI 1.23-1.53, p < 0.001), as was atypical atrial flutter (HR 2.63, 95% CI 1.97-3.50; p < 0.0001). CONCLUSION: Extra-pulmonary vein ablation during first-time PAF ablation remains common in real-world practice but is associated with worse outcomes including repeat ablation, cardioversion, AAD use, atrial flutter, and progression to persistent AF.