Key result
Adding posterior wall ablation to PVI fails to reduce AF/AFL recurrence in pulsed field ablation.
Why the study?
Posterior wall ablation is being added to pulmonary vein isolation during pulsed field ablation for persistent AF to improve procedural efficacy, but few studies have objectively assessed the impact of this strategy on outcomes.
Does adding posterior wall ablation to pulmonary vein isolation reduce the recurrence of atrial fibrillation or atrial flutter in patients with persistent atrial fibrillation undergoing pulsed field ablation?
Cohort (n=230)
Does adding posterior wall ablation to pulmonary vein isolation reduce the recurrence of atrial fibrillation or atrial flutter in patients with persistent atrial fibrillation undergoing pulsed field ablation?
In patients with persistent atrial fibrillation undergoing pulsed field ablation, adding posterior wall ablation to pulmonary vein isolation was safe but did not reduce atrial arrhythmia recurrence compared to pulmonary vein isolation alone over a 7-month mean follow-up.
Adding posterior wall ablation was not associated with lower recurrence; leaves open optimal pulsed field ablation strategies in persistent AF.
Background Pulsed field ablation (PFA) is becoming widely used in patients undergoing catheter ablation of atrial fibrillation (AF). Posterior wall (PW) ablation is being added to pulmonary vein isolation (PVI) in patients with persistent AF (PeAF) to improve procedural efficacy, especially since risk of inadvertent damage to the esophagus has been eliminated with use of PFA. There are few studies that objectively assess the impact of this strategy on outcomes. Objective To compare the recurrence of AF/atrial flutter (AFL) following PVI PFA alone and PVI with PW ablation PFA in patients with PeAF. Methods We enrolled patients with PeAF who underwent ablation using 3 FDA approved PFA systems (PulseSelect, Affera, Medtronic; FaraPulse, Boston Scientific). Recurrences of AF/AFL following a 60-day blanking period were determined. Results The cohort included 230 patients (69 ± 10 yrs, 70% male, CHA2 DS2VASc 2.9 ± 1.6) who underwent PVI alone (74 [32%]) or underwent PVI with PW ablation (156 [68%]). Patients ablated with PulseSelect were more likely to have PVI alone, whereas PVI and PW ablation was more common when the FaraPulse system was used (Table). There were no major complications observed. A third of patients had continuous ECG monitoring. During a mean follow-up of 211 ± 120 days, there were similar AF/AFL recurrences in PVI alone and PVI + PW ablation groups, 25 (34%) and 50 (32%) respectively (hazard ratio [HR], 0.88; 95% CI, 0.55-1.41; p=0.607) (Figure). Conclusions In this non-randomized cohort of 230 patients with PeAF followed for a mean of 7 months, we observed no difference in recurrence of atrial arrhythmias whether the PW was or was not ablated at the time of PVI. Safety of PW ablation and PVI was similar to PVI only. These data suggest need to better identify the cohort of patients who derive benefit from additional ablation.TableFigure
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Musat et al. (2026) conducted a cohort in Persistent atrial fibrillation (PeAF) (n=230). Pulmonary vein isolation (PVI) with posterior wall (PW) pulsed field ablation vs. Pulmonary vein isolation (PVI) pulsed field ablation alone was evaluated on Recurrence of atrial fibrillation or atrial flutter (AF/AFL) following a 60-day blanking period (HR 0.88, 95% CI 0.55-1.41, p=0.607). Adding posterior wall ablation to PVI during pulsed field ablation for persistent AF did not significantly reduce AF/AFL recurrence compared with PVI alone (32% vs 34%; HR 0.88; 95% CI 0.55-1.41).
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