Pulsed-field versus radiofrequency ablation for posterior wall isolation in persistent atrial fibrillation: a propensity-matched outcome analysis

Abstract Introduction Left atrial posterior wall isolation (LAPWI) is increasingly used as an adjunct to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PerAF), but the optimal ablation modality remains uncertain. Pulsed-field ablation (PFA) may offer advantages over radiofrequency (RF) due to its non-thermal mechanism and improved tissue selectivity. Methods and Results In this single-center study, 92 patients with PerAF and posterior low-voltage substrate identified via high-density mapping were treated with either PFA (n = 46) or RF ablation (n = 46) for PVI plus LAPWI. Remapping was performed to confirm complete electrical isolation. Groups were 1:1 propensity score–matched fro analysis. The primary endpoint was freedom from any sustained atrial arrhythmia (30 seconds) at 12-month follow-up, assessed via structured Holter-ECG monitoring at 3, 6, and 12 months. Complete PWI was achieved in 100% of PFA and 95.7% of RF patients. Procedure time was significantly shorter with PFA (median 68.2 min vs 86.8 min, p 0.01). Arrhythmia-free survival at 12 months was similar between groups (58.7% vs 52.2%, p = 0.57). Multivariable Cox regression identified LA diameter, BMI 30, and hypertension as independent predictors of arrhythmia recurrence. Complication rates were low and comparable. Conclusion In patients with PerAF and posterior low-voltage substrate, PFA and RF yielded similar arrhythmiafree survival at one year. PFA was associated with shorter procedure times and high rates of posterior wall isolation, supporting its potential as a more efficient alternative to RF in this setting.