Does coronary sinus cycle length prolongation predict arrhythmia-free survival in patients with persistent atrial fibrillation undergoing PVI and LAPWA with pulsed field ablation?
In patients with persistent AF undergoing pulsed field ablation, a coronary sinus cycle length prolongation >23.5% after PVI and posterior wall ablation predicts a lower risk of arrhythmia recurrence.
Abstract Background Pulmonary vein isolation (PVI) alone is often insufficient for catheter ablation (CA) of persistent atrial fibrillation (PerAF), and the benefit of additional left atrial posterior wall ablation (LAPWA) remains controversial. Purpose We investigated whether signals recorded with a pentaspline pulsed field ablation (PFA) catheter can identify PerAF patients with rapid LAPW activity who may benefit from LAPWA. Additionally, we evaluated whether PFA-induced atrial fibrillation cycle length (AF-CL) prolongation, measured from the coronary sinus (CS), predicts arrhythmia-free survival. Methods In this multicenter observational study, consecutive PerAF patients undergoing first-time ablation with a pentaspline PFA catheter were included. PVI and LAPWA were performed in all cases. AF-CL was measured using the FARS-10 method at three time points: baseline, post-PVI, and post-LAPWA, using distal CS signals. LAPW-CL was measured post-PVI from multiple LAPW positions, with the fastest value retained. Arrhythmic recurrence was defined as any atrial tachyarrhythmia (ATA) lasting 30 seconds beyond the 2-month blanking period. Results Among 270 included patients (mean age 67.1 ± 11.0 years; 29.6% female). Median AF duration was 12 9-20 months. The overall 12-month ATA-free survival was 72.6%. "Fast LAPW activity" was defined as a LAPW-CL value shorter than the mean LAPW-CL of the entire cohort (191.4±2.4 msec; ≤ 190 msec). Fast LAPW activity was not associated with arrhythmia recurrence (OR 1.263, 95% CI: 0.739–2.160; p=0.393). In contrast, a greater CS-CL prolongation following PVI + LAPWA was independently associated with lower recurrence risk (OR for arrhythmia recurrence 0.298, 95% CI: 0.017–0.520; p0.001). A CS-CL increase 23.5% from baseline had a sensitivity of 0.65 and specificity of 0.72 for predicting ATA-free survival. Conclusion Post-PVI fast LAPW activity does not predict recurrence after LAPWA in PerAF patients. However, a CS-CL prolongation 23.5% after LAPWA may serve as a useful real-time marker of effective substrate modification and arrhythmia control
Bianchini et al. (Mon,) studied this question.