Learning curve of pulsed field ablation for persistent atrial fibrillation with posterior wall isolation: procedural efficiency across the first 120 cases

Background Pulsed field ablation (PFA) enables rapid pulmonary vein isolation and posterior wall isolation in patients with atrial fibrillation (AF). However, data describing the learning curve and procedural efficiency during early adoption, particularly for posterior wall isolation in persistent AF, remain limited. Purpose To evaluate the learning curve of pulsed field ablation for persistent atrial fibrillation by analyzing procedural efficiency and safety across consecutive cases, with specific focus on posterior wall ablation. Methods This single-center observational study included 120 consecutive patients with persistent atrial fibrillation undergoing first-time catheter ablation using a standardized strategy of pulmonary vein isolation combined with posterior wall isolation performed exclusively with pulsed field ablation. Patients were divided into three consecutive tertiles according to procedural order (first, second, and third 40 cases). Total procedural duration, posterior wall ablation time, fluoroscopy time, acute procedural success, and major periprocedural complications were prospectively recorded and compared across tertiles. Results Baseline clinical characteristics were comparable among tertiles. Total procedural duration progressively decreased across experience tertiles, from 60 ± 2 minutes in the first tertile to 55 ± 1 minutes in the second tertile and 50 ± 2 minutes in the third tertile. Posterior wall ablation time showed a consistent reduction, with a decrease of 2 minutes between the first and second tertiles and a further reduction of 1 minute between the second and third tertiles. Fluoroscopy time also decreased significantly across tertiles, from 9 ± 1 minutes in the first tertile to 7 ± 1 minutes in the second tertile and 5 ± 2 minutes in the third tertile. Acute procedural success was maintained throughout all phases, with no increase in major periprocedural complications during early or later experience. Conclusion In patients with persistent atrial fibrillation undergoing pulmonary vein isolation plus posterior wall isolation, pulsed field ablation demonstrated a rapid and favorable learning curve. Procedural efficiency improved progressively with experience, particularly for posterior wall ablation, without compromising safety or acute success. These findings support the reproducibility and scalability of PFA for complex ablation strategies in routine clinical practice.