Comparison of two techniques in the use of electroporation for transcathether ablation of atrial fibrillation

A few years after its introduction into atrial fibrillation (AF) ablation procedures, electroporation (PFA) is now used in several available ablation catheters. This widespread adoption is due to the non-thermal nature of the energy employed, as well as the demonstrated safety and effectiveness of PFA-based ablation. However, data comparing the different catheters are not yet available in the scientific literature.

The aim of this study is to compare two different tecnhology using PFA for the transcathether ablation of AF.

We conducted a retrospective observational study enrolling patients who underwent catheter ablation for paroxysmal and persistent AF between August 2022 and October 2024. The patients were treated with two catheters that employ PFA: a multielectrode pentaspline catheter (FR, n = 264, 85%) and a variable-loop circular catheter in combination with 3-dimensional mapping system (VR, N = 45, 15%). All procedures were performed following the manufacturer's work flow. All FR procedures (n = 264, 85%) were conducted under general anesthesia, while VR procedures (N = 4, 1%) were performed under deep sedation. Intracardiac ultrasound was used in 231 (88%) of the FR procedures and in all of the VR procedures.

A total of 309 patients were enrolled, with n = 264 (85%) in the FR group and N = 45 (15%) in the VR group. The two populations were comparable (Table 1). Procedural data show that pulmonary vein isolation was successfully achieved in all patients. Additional lesions were delivered in n = 97 (36%) of the FR group and N = 11 (24%) of the VR group (p = 0.07), mostly at the posterior wall (n = 58 [22%] in FR; N = 8 [18%] in VR), p = 0.19. The VR group showed a shorter procedural duration (65 [60–75] minutes vs 70 [60–86] minutes; p = 0.017) and shorter fluoroscopic time (8 [7–11] minutes vs 18 [15–23] minutes; p = 0.00001), but a longer time in the left atrium (30 [25–40] minutes vs 20 [15–25] minutes; p = 0.00001). The rate of peri-procedural complications was similar between the two techniques (n = 3 [1%] FR; N = 1 [2%] VR), with no major complications documented.

Both techniques were demonstrated to be safe and effective in the acute setting. However, the shorter procedural time and reduced radiation exposure provide a benefit for patients in the VR group. Additionally, the integration of electroanatomical mapping may prove useful in identifying areas of low voltage to determine whether and where lesions should be extended beyond pulmonary vein isolation, as well as in identifying anatomical variants such as common pulmonary vein ostia (N = 19 [42%] in the VR group), which may represent blind spots in ablation when performed solely with fluoroscopic guidance (FR). We are currently awaiting an increase in the sample size of the VR group and the implementation of follow-up data to determine whether these factors translate into clinical implications regarding arrhythmic recurrence rates.