Pulsed-field ablation for atrial fibrillation in patients with chronic kidney disease: acute safety and efficacy

Background Pulsed-field ablation (PFA) offers a nonthermal and tissue-selective alternative with promising safety data; however, evidence in patients with chronic kidney disease (CKD) is limited. Purpose This study aimed to evaluate the safety and efficacy of PFA for atrial fibrillation (AF) in patients with CKD. Methods Patients with AF who underwent their initial catheter ablation with PFA were enrolled. Patients on dialysis were excluded. Biomarkers for hemolysis (haptoglobin, lactate dehydrogenase), myocardial injury (creatine kinase [CK], CK-MB, troponin I [TnI]), and renal function (creatinine, estimated glomerular filtration rate [eGFR]) were assessed before and 24 hours after procedure. Renal function and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were assessed before and at one-month post procedure. CKD was defined as eGFR < 60 mL/min/1.73m² before procedure. Results A total of 187 patients (72.0 [65.0, 77.0] years old, 122 [65.2%] male, 112 [59.9%] paroxysmal AF) were included; 100 (53.5%) patients in the non-CKD group, 87 (46.5%) patients in the CKD group. The CKD group was significantly older, had a lower body mass index, and showed a higher prevalence of heart failure. CHA2DS2-VASC score and baseline NT-proBNP levels were significantly higher, and left ventricular ejection fraction was lower in the CKD group than in the non-CKD group. After procedure, the increase in TnI level was significantly higher (16288 [11056, 26621] vs. 13162 [9857, 19496] pg/mL, p = 0.026) and eGFR improved (0.93 [-3.16, 4.83] vs. -1.16 [-6.76, 3.29], p = 0.031) in the CKD group. However, no significant differences were observed in the changes in other biomarkers. Procedure-related complications and acute kidney injury (AKI) were observed in 12 (6.4%) and 4 patients (2.1%), respectively. No significant differences were identified between the CKD and non-CKD groups, with 6 (6.9%) vs. 6 (6.0%) cases (p = 1) and 2 (2.3%) vs. 2 (2.0%) cases (p = 1), respectively. All patients in the CKD group who experienced complications underwent additional procedures other than pulmonary vein isolation (PVI) (6 [14.6%] vs. 0 [0.0%], p < 0.01). However, in the non-CKD group, there was no association between additional procedures other than PVI and complications. At one-month follow-up, eGFR significantly improved in the CKD group, with no difference in the non-CKD group (3.59 [0.18, 5.67] vs. 1.13 [-3.07, 6.41], p = 0.012). While NT-proBNP levels decreased in both groups, the reduction was more pronounced in the CKD group (235.4 [-16.6, 851.9] vs. 23.8 [-31.9, 376.9] pg/mL, p < 0.01). Conclusions PFA for AF can be safely performed even in patients with CKD, and improvements in eGFR and reductions in NTproBNP levels were observed, indicating that PFA is an effective treatment. However, when additional treatments other than PVI are performed in patients with CKD, careful attention to complications is necessary.