Pulsed field, cryoballoon or radiofrequency catheter ablation of atrial fibrillation in hypertrophic cardiomyopathy

BACKGROUND: Patients with hypertrophic cardiomyopathy (HCM) exhibit suboptimal outcomes after atrial fibrillation (AF) ablation. OBJECTIVE: We sought to compare the efficacy, safety and long-term outcomes of pulsed field ablation (PFA), cryoballoon (CB) and radiofrequency (RF) ablation for AF in HCM. METHODS: Patients with HCM undergoing de novo AF ablation were retrospectively included from 11 centers. Procedure characteristics, safety endpoints and 24-month outcomes were assessed. The primary endpoint was atrial arrhythmia recurrence (AF/atrial tachycardia). RESULTS: A total of 364 patients with HCM (61.7±11.1 years, 74.5% male, 47.5% paroxysmal AF) underwent AF ablation with PFA (n=84), CB (n=50) or RF (n=230). Procedure-related complications occurred in 1.2%, 4.0% and 5.2% with PFA, CB and RF, respectively (p=0.344). Cumulative 24-month freedom from atrial arrhythmia recurrence was 48.6%. PFA was associated with reduced atrial arrhythmia recurrence compared with RF (adjusted HR, 0.57; 95% CI, 0.36-0.91; p=0.018), while CB showed no significant difference with either group (adjusted HR versus RF, 0.71; 95% CI, 0.42-1.21; p=0.212). In exploratory secondary analyses, PFA was associated with reduced cardiovascular hospitalization (adjusted HR, 0.43; 95% CI, 0.23-0.80; p=0.008), and greater improvement in NYHA class compared with RF (p=0.032), while CB showed no significant difference. Heart failure hospitalization, repeat ablation, ventricular arrhythmias, stroke/transient ischemic attack and mortality did not differ significantly between ablation modalities. CONCLUSION: PFA for catheter ablation of AF in HCM was associated with reduced 24-month atrial arrhythmia recurrence, with exploratory signals of fewer cardiovascular hospitalizations and improved NYHA class compared with RF, while CB showed no significant difference.