Mapping workflow trends in pulsed-field ablation procedures: an international glimpse

As pulsed field ablation (PFA) is increasingly used in the EP lab, the use of mapping, fluoroscopy, and intracardiac echocardiography has adjusted in response. However, a quantification of use trends on an international scale has not been established.

The objective of this analysis is to identify mapping workflow trends and high-density mapping utilization in PFA procedures.

Acute observational data from 468 PFA procedures for AF was prospectively collected from 81 operators at 38 centers in the US, Europe, and Australia from Feb-Oct 2024. Ablation strategy and mapping catheter choice were at operator’s discretion. All cases in this analysis used a 3D electroanatomic mapping software (EnSite X system) and a pentaspline PFA catheter (PFAC).

In this cohort, operators used a high-density mapping catheter (HDMC, HD Grid, n=338), a circular mapping catheter (CMC, n=48), a PFAC (n=3), a combination (n=2), or other. General procedural metrics, including PVI time, mapping time, and mapping utilization, were assessed.

The most commonly treated diagnosis was de novo paroxysmal AF (dnPAF, n=213), then de novo persistent AF (dnPsAF, n=121), redo PsAF (rPsAF, n=83), and redo PAF (rPAF, n=51). HDMC was the most frequently utilized mapping catheter for all indications (Figure 1).

Voltage maps were the most commonly used display for all mapping catheters (70.7% of HDMC cases, 86.3% of CMC cases, 100% of PFAC cases, and 66.7% of PFAC+HDMC cases), followed by local activation time (LAT) mapping (13.8% of HDMC cases and 13.7% of CMC cases). Notably, Voltage map was the only display used in PFAC cases. Mapping as a post-ablation PVI assessment method was used in a majority of HDMC, CMC, and PFAC+HDMC cases (63.9%, 71.1%, and 100%, respectively), and only used in 33.3% and 18.2% of PFAC and Other cases, respectively. The average number of gaps found in the HDMC, CMC, and PFAC+HDMC groups was 1.4±0.11 (338 patients), 1.4±0.3 (90 patients), and 1.5±0.5 (2 patients) (p=.92). There were 0 gaps found in the PFAC group (3 patients).

Average PVI and mapping times by mapping catheter type are shown in Figure 2. The HDMC group had the shortest PVI time and was not significantly different than the PFAC cases (p=0.16) and was significantly different than the CMC cases (p<.05). There were no significant differences in mapping times among the 4 groups (p=0.95).

The results from this international cohort show that, regardless of case type, a high-density mapping catheter is the most common choice, with the majority of cases utilizing a catheter other than the PFA catheter for mapping. Although there was no significant difference in mapping time or number of gaps identified among the four groups, use of the HDMC was associated with shorter PVI times. These results highlight international trends as workflows adjust to a novel ablation technology and showcase the impact of high-density mapping on procedural efficiency.Figure 1.

Mapping catheter usage