Workflow efficiency of nanosecond versus microsecond pulsed field ablation for atrial fibrillation

Background Pulsed field ablation (PFA) is a novel non-thermal energy modality that delivers high-voltage, ultra-short electrical pulses (microseconds to nanoseconds) to induce myocardial-selective irreversible electroporation. Nanosecond PFA ablation system represents a next-generation technology utilizing nanosecond-duration high-voltage electrical pulses (nsPFA™), inducing regulated cell death while sparing non-cellular components. Real-world data comparing workflow performance between ns and ms-based PFA remain limited. Aim To compare workflow characteristics between a nsPFA system and a conventional msPFA during atrial fibrillation ablation. Methods This is a retrospective, two-centre, comparative study including consecutive patients undergoing first-time catheter ablation for paroxysmal atrial fibrillation. Exclusion criteria included prior atrial fibrillation ablation, persistent atrial fibrillation, left ventricular ejection fraction <40% and contraindications to anticoagulation. This study evaluated 348 patients undergoing AF ablation using PFA system. A total of 43 patients for the nsPFA group and 43 patients for the msPFA group were generated by propensity matching, based on calculated risk factor scores, using a logistic model. All cases followed a standardised workflow including three-dimensional electroanatomical mapping and pulmonary vein isolation with confirmation of entrance and exit block. Additional left atrial target lesions were performed at the operator’s discretion. Workflow endpoints were fluoroscopy time, left atrial dwell time (from transseptal access to final catheter exit), and total procedure duration (skin-to-skin, from groin puncture to sheath removal). Additional procedural metrics included number of applications per vein and per patient. Results Baseline characteristics were comparable between groups (nsPFA group: 58.1 ± 9.6 years, 27.9% female; msPFA group: 62.4 ± 8.7 years, 33.8% female). Pulmonary vein isolation was successfully achieved in all patients of both groups (100%). Adjunctive left atrial ablation was performed in 100% of patients in the ns group and 87% in the ms group. In the nsPFA cohort, the mean number of applications required to achieve pulmonary vein isolation was 2,7 ± 0.2 per vein, corresponding to 18,4 ± 4,6 applications per patient. In the msPFA cohort, the mean number of applications per vein was 18.0 ± 4.4, with 70 ± 18.1 applications per patient (p <0.001) With respect to predefined workflow endpoints, the ns group demonstrated shorter total procedure duration (35.7 ± 8.57 minutes vs 84.8 ± 11.8 minutes, p <0.001), comparable fluoroscopy time (17.0 ± 3.15 vs 16.97 ± 2.6; p=0.91), and shorter left atrial dwell time (10 ± 4.0 vs 59.4 ± 18.3 minutes; p <0.001) compared with the ms group. Conclusion NsPFA was associated with improved procedural workflow compared with msPFA, showing comparable fluoroscopy exposure, a reduction in LA dwell time and total procedure duration.