Association of early recurrence with extended lesion sets beyond pulmonary veins in patients with atrial fibrillation undergoing pulsed-field ablation

Introduction Prior studies have reported a significant association between early (ER) and late recurrence following catheter ablation for atrial fibrillation (AF). However, there is limited data on the factors contributing to ER post-pulsed field ablation (PFA). We aimed to assess the link between extended ablation and ER in AF patients undergoing PFA. Methods Consecutive AF patients undergoing PFA at our center were included in this prospective analysis and classified into 2 groups based on the ablation strategy; Group 1: pulmonary vein isolation (PVI) only and Group 2: PVI+ extra-PV ablations. Procedures were performed by skilled and experienced electrophysiologists. Extra-PV lesions mostly included isolation of left atrial posterior-wall and superior vena cava. Patients remained on previously ineffective anti-arrhythmic drugs during the 2-month blanking period. ER was defined as any recurrence occurring within the first 3 months of the procedure. Arrhythmia monitoring was performed using event recorders, wearable patches or smart watches. Results A total of 3,364 consecutive AF patients [paroxysmal AF (PAF): 1648 (49%)] were classified into Group 1: 1,312 [PAF: 1055 (80.4%)] and Group 2: 2,052 [non-PAF: 1459 (71%)]. ER was observed in 572 (17%) patients including 282 (21.5%) and 290 (14.13%) from group 1 and 2 respectively (p<0.001). Mean time to recurrence was 54±27 days. In the contingency-table analysis, PVI-only was associated with 66% higher risk of ER compared to PVI+ ablation-strategy (Odds Ratio: 1.66, p<0.001). Conclusion In this large prospective single-center series, contrary to prior findings, PVI-only ablation strategy was seen to be associated with significantly higher risk of early recurrence.