Vascular complications of pulsed-field ablation of atrial fibrillation using a streamlined procedural workflow - when less is not more

Pulsed-field ablation (PFA) of atrial fibrillation (AF) has recently emerged as standard technique to achieve pulmonary vein isolation (PVI). Though complication rates have been reported to be lower with PFA compared to thermal ablation, further attempts should be made to minimize procedure-related complications.

We aimed to assess vascular complications of PFA-based PVI using a streamlined procedural workflow including ultrasound-guided vascular access and access closure by subcutaneous Z-suture only.

Consecutive patients who were scheduled for first-time catheter ablation of paroxysmal or persistent AF between December 2023 and September 2024 underwent PFA-based PVI following a streamlined procedural workflow. All procedures were performed after ≥4 weeks of uninterrupted oral anticoagulation in deep sedation and fluoroscopy-guided without use of electroanatomical mapping. No magnetic resonance or computed tomography imaging of the PVs nor transesophageal echocardiography was routinely performed. All patients underwent ultrasound-guided vascular access for a short 7F and long 13F stearable sheath (16.8F outer diameter), and access closure using a single subcutaneous Z-suture only without pressure bandage. Peri- and postoperative complications were assessed and patients followed for a minimum of 30 days for the purpose of the study.

A total of 216 consecutive patients (67±11 years; 44% female; 54% persistent AF) were included for analysis. The overall rate of severe complications requiring intervention was 0.5% (1/216). No patient experienced a non-vascular complication related to device-specific PFA-based PVI (Table). Major vascular complications occurred in 2 patients (0.9%), of which one required intervention: 1 transient inferior ST-segment elevation due to coronary air embolism, and 1 accidental puncture of the inferior epigastric artery requiring coiling. Minor vascular complications occurred in 29.6% (64/216) of patients including acute bleeding after Z-suture closure requiring additional pressure bandage in 15.3% (33/216) and postinterventional major superficial hematoma in 5.6% (12/216). The average time from intervention to hospital discharge was 1.04±0.22 days with no difference between patients with and without vascular complication (1.05±0.21 vs. 1.04±0.23 days; p=0.83).

Our proposed streamlined procedural workflow for PFA-based-PVI is highly effective and safe with an associated low rate (0.5%) of severe complications requiring intervention. However, minor bleeding complications frequently occurred with application of a single subcutaneous Z-suture only. Routine use of a pressure bandage should be reconsidered.

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