Role of age in pulmonary vein isolation procedures in the new pulsed-field-ablation era - a single center experience.

Introduction 

Ablation by pulmonary vein isolation (PVI) with radiofrequency ablation (RF) or cryoballon ablation (CBA) has emerged to the standard interventional therapy in patients with atrial fibrillation (AF). However, in elderly patients PVI is still not performed as a routine therapy based on data showing lower success and higher complication rates. Recently the new ablation technology pulsed-field-ablation (PFA) was introduced with the goal to improve PVI procedures with respect to safety, procedural and clinical outcome, potentially providing also a better ablation tool for elderly AF patients. Objective of this single center analysis was to evaluate the impact of age (<75a, ≥75a, ≥80a, ≥85a) on choice of ablation modality (PFA, RF and CBA) and its relation to procedural outcome.

Methods

We retrospectively analyzed 250 patients, of which 71 were ≥75a, 35 ≥80a, and 7 ≥85a, who all underwent 1^st do PVI for AF treatment. We analyzed the type of PVI (PFA, RF, CBA), procedure duration, fluoroscopy time, radiation dosage and use of contrast agent. In addition, all peri-interventional complications within 30d were evaluated. All PVI procedures were performed by two experienced operators. 

Results

In this cohort 57% were male, median BMI was 25.7 kg/m², 86% had a diagnosis of hypertension, 14% with CKD, 21% diabetes, median CHA₂DS₂-Vasc score was 5. Our analysis showed consistently the most frequent and similar use of PFA (>50% of all cases) in all age groups, while the percentage of RF procedures declined form 24, 18, 14 to 0% by higher age group. However, CBA showed a huge rise in the group ≥85a from to 18, 14, 14 up to 43% (figure A). Procedural outcome was analyzed per age group and the within the age groups between the different modalities (figure B and C). We observed that procedural parameters did not differ significantly between age groups. Nevertheless, when stratifying patients according to the ablation modality there were significant differences (p<0.05) between the three modalities for radiation dosage and contrast agent being higher with CBA (vs. PFA and RF) throughout the age groups. Furthermore, PFA showed consistently shorter procedure time for all age groups vs. RF and CBA. With respect to complications, we did not observe more complications in the higher age groups, stratified for ablation modality our analysis revealed lower rates for PFA and CBA vs. RF (figure D). 

Conclusion

In the era of PFA most 1^st do PVI procedures were performed with PFA independent from age throughout all groups. The use of RF declined, while CBA increased towards the elderly patients in the group ≥85a.  Procedural parameters with PFA were consistently favorable without signs of a higher complication rates independent form higher age. These results provide first insights into the role of PFA as the potential preferred PVI ablation modality in elderly AF patients. Nevertheless, further data and controlled trials are required to confirm this hypothesis.