Efficacy and safety of extended pulsed-field ablation in persistent atrial fibrillation

Persistent atrial fibrillation (AF) presents significant challenges for rhythm control, and comprehensive ablation strategies are being explored to enhace outcomes. Pulse-field ablation (PFA) with FARAPULSE offers a non-thermal approach that may approach that may yield superior safety and efficacy.

Purpose The aim is to evaluate the efficacy of FARAPULSE PFA in patients with persistent atrial fibrillation by performing an extended pulmonary vein ablation (PVI) that includes the posterior wall and mitral isthmus isolation.

A total of 156 patients with persistent AF underwent PFA using FARAPULSE between November 2022 and August 2024. The cohort included 134 men (86%), with a mean age of 60±10 years. The mean left ventricular ejection fraction (LVEF) prior to the procedure was 46±15%, and the average duration of AF was 389±116 days. Ablation involved PV isolation, posterior wall isolation in 145 (97%) patients, and mitral isthmus ablation in 130 patients (85%).

All PVs and posterior walls were successfully isolated, with mitral isthmus block achieved in all but two patients. Over a mean follow-up of 270 days, 38 patients (24%) experienced atrial tachyarrhythmias (32 AF recurrences and 6 atrial flutter episodes). Kaplan-Meier analysis illustrated these outcomes (Figure 1). Post-ablation, mean left ventricular ejection fraction (LVEF) improved to 55±8 %. Only two patients experienced complications: one case of vascular complication requiring surgery and one case of hemoglobinuria with reversible renal insufficiency.

Extended ablation using FARAPULSE PFA in patients with persistent AF effectively maintains sinus rhythm in a significant proportion of cases and leads to notable improvement in left ventricular function. Further studies with extended follow-up are recommended to confirm these findings.