Are there anatomic and geometric features of the pulmonary veins associated with reconnection after pulsed-field ablation of atrial fibrillation? a cardiac computed tomography study

Pulmonary vein isolation (PVI) using pulsed field ablation (PFA) is an emerging technique for the treatment of atrial fibrillation (AF). However, the recurrence rate of AF remains significant, and the durability of PVI incomplete. The impact of anatomical and geometrical variations of the pulmonary vein (PV) ostia on PVI durability is unknown.

In this multicenter, retrospective study, we used pre-ablation CT scans to measure the anatomical and geometrical characteristics of the ostia of each PV in patients treated with PFA using the pentaspline catheter. These patients subsequently experienced arrhythmia recurrence and underwent a second procedure with high-resolution mapping of the left atrium, allowing the assessment of PVI durability for each PV. A multivariate logistic regression was performed to evaluate predictors of PV reconnection risk.

A total of 99 patients, corresponding to 398 PVs, were included. Up to 69% of patients had at least one reconnected PV, and the PV reconnection rate ranged from 30% to 37%, with no significant difference between each type of PV. Considering all typical PVs together, a significant lateral angle difference between two ipsilateral PVs (adjusted odds-ratio [aOR] 1.01 per 1° increase, 95% confidence interval [CI] 1.00 – 1.02; P = 0.03) was associated with reconnection. A wider ostium was associated with reconnection of the left inferior PV (aOR 1.18 per 1 mm increase, 95% CI 1.02 – 1.39; P = 0.03). No other anatomical factors predicted reconnection of the other PVs individually. The use of a 35 mm PC was associated with fewer PV reconnections overall (aOR 0.52, 95% CI 0.28 – 0.95; P = 0.04), particularly for the right superior PV.

The impact of the anatomical and geometrical characteristics of PVs on PV reconnection was generally limited, confirming the ability of the PFA pentaspline catheter to adapt to various PV anatomies. However, the high reconnection rate encourages further technological improvements.