Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

Abstract

BACKGROUND Pulmonary vein isolation (PVI) alone is insuf ficient to treat many patients with persistent atrial fibrillation (PersAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of ef ficacy, perhaps limited by the dif ficulty in achieving lesion durability amid concerns of esophageal injury. OBJECTIVES This study aims to compare the safety and effectiveness of PVI + LAPW ablation vs PVI in patients with PersAF using pulsed- field ablation (PFA). METHODS In a retrospective analysis of the MANIFEST-PF (Multi-National Survey on the Methods, Ef ficacy, and Safety on the Post-approval Clinical Use of Pulsed Field Ablation) registry, we studied consecutive PersAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of $30 seconds. Safety outcomes included the composite of acute and chronic major adverse events. RESULTS Of the 547 patients with PersAF who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years of age, P = 0.08), had a lower CHA 2 DS 2 -VASc score (2.3 +/- 1.6 vs 2.6 +/- 1.6, P = 0.08), and were more likely to receive electroanatomical mapping (48.1% vs 39.0%, P = 0.07) and intracardiac echocardiography imaging (46.1% vs 17.1%, P < 0.001). The 1-year Kaplan -Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI + LAPW: 66.4%; 95% CI: 57.6%-74.4% vs PVI: 73.1%; 95% CI: 68.5%-77.2%; P = 0.68) and propensitymatched cohorts (PVI + LAPW: 71.7% vs PVI: 68.5%; P = 0.34). There was also no signi ficant difference in major adverse events between the groups (2.2% vs 1.4%, respectively, P = 0.51). CONCLUSIONS In patients with PersAF undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months. (J Am Coll Cardiol EP 2024;10:900 -912) (c) 2024 by the American College of Cardiology Foundation.