Introduction:
Pulmonary vein (PV) isolation by means of pulsed field ablation (PFA) has demonstrated favorable safety and efficacy results in the initial atrial fibrillation (AF) ablation procedures. Data regarding its use in patients undergoing repeat AF ablation remain limited. This study aimed to evaluate procedural characteristics, lesion patterns, and clinical outcomes of the PFA in a redo AF cohort.
Methods:
Consecutive patients undergoing repeat AF ablation using pentaspline (Farawave™) or focal PFA (Farapoint™, both Boston Scientific, Germany) catheter were identified from a prospective single-center registry. Clinical characteristics, prior ablation history, intraprocedural findings, procedural metrics, and safety outcomes were collected. Acute procedural success and follow-up outcomes were assessed. Three-dimensional electroanatomical mapping was performed using the Opal HDx system (Boston Scientific, Germany).
Results:
Between November 2023 and June 2026, a total of 93 patients undergoing repeat AF ablation using PFA were included. Mean age was 64.0 ± 11.5 years, 63.4% were male, mean body mass index was 26.4 ± 5.0 kg/m², and the mean CHA₂DS₂-VASc score was 2.9 ± 1.5. Mean left ventricular ejection fraction was 57 ± 7% and a mean left atrial (LA) diameter of 42 ± 8 mm. Persistent AF was present in 58.1% of patients. The most common previous ablation modality was cryoballoon in 67.7% (n=62), radiofrequency in 17.2% (n=16) and surgical Maze ablation in 3.2% (n=3). Median time to repeat procedure was 39 (14.5; 105) months. At repeat study, 45 (48.5%) patients demonstrated durable isolation of all PVs. Single-vein reconnection was observed in 17 (18.3%), two-vein reconnection in 16 (17.2%), and ≥3 reconnected veins in 15 (16.1%) patients. The right superior PV was the most frequently reconnected vein (38.7%). A sole re-PVI strategy was applied in 20 (21.5%). Additional ablation beyond PV isolation was performed in 73 (78.5%) patients, including posterior wall isolation (PWI) in 63 (67.7%), mitral isthmus ablation in 4 (4.3%), cavotricuspid isthmus ablation in 7 (7.5%), and other lesions in 19 (20.4%). An additional radiofrequency or focal-tip PFA catheter ablation catheter was used in 19 (20.4%)), and 11 (11.8%), respectively. Median LA time was 110 [IQR 66.0] minutes, and median dose area product was 501 cGyxcm2 [IQR 391.5]. No major procedural complications occurred. One minor complication (0.9%, pulmonary infiltrate, conservative treatment) was observed. After a median follow-up of 8 months, atrial arrhythmia recurrence was documented in 30/58 (51.7%) of patients. Recurrence occurred in 58.3% of patients undergoing re-PVI only, and 48.9% undergoing ablation beyond PVI (p=0.75).
Conclusion:
Repeat AF ablation using a fully integrated mapping and PFA platform was safe and feasible in a redo population, with no major complications observed and favorable mid-term arrhythmia outcomes. PV reconnection remained common, particularly in the right-sided PVs, although additional ablation beyond re-PVI was required in most patients. The pentaspline PFA system appears particularly well suited for anatomical redo strategies, including re-PVI and posterior wall isolation, whereas individualized substrate- or extra-PV trigger-guided ablation may be addressed using focal ablation catheters. Larger studies are warranted to validate these findings.
