Comparison of pulsed field ablation and thermal ablation modalities for pulmonary vein isolation in patients with atrial fibrillation and heart failure

Evangelos Mavrakis (Essen)1, D. Vlachopoulou (Essen)1, J. Bohnen (Essen)1, I. M. Rudolph (Essen)1, M. Rattka (Essen)1, C. Jungen (Essen)1, T. Rassaf (Essen)1, S. Mathew (Essen)1

1Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland


Pulmonary vein isolation (PVI) is the gold standard for atrial fibrillation (AF) ablation and can be achieved by a variety of methodical approaches. While thermal ablation modalities, such as cryoballoon (CB) and radiofrequency ablation (RFA), have been established as the standard of care over the last decades, PFA has recently been introduced as a novel non-thermal modality showing similar results in terms of safety and procedural efficiency. Despite the high incidence of AF in heart failure (HF) patients, data comparing rhythm outcomes of HF patients undergoing PVI by either PFA or thermal ablation (RFA/CB) are limited.
This study’s aim was to compare the efficacy and safety of PFA for AF ablation versus CB/RFA in HF patients. 
Consecutive HF patients with preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction undergoing PVI for AF by either PFA or CB/RFA at our institution were included. The primary end-point was time to death or recurrence of AF. Secondary end-points were periprocedural complications.
We included 140 HF patients who underwent PVI either by PFA (PFA group, 76 patients) or thermal ablation approaches (TA group, 64 patients). Our patients had a mean age of 70 years and were predominantly male (63%). There was no significant difference in the baseline characteristics and for the type of AF between both groups. In total we identified 57 patients (41%) with paroxysmal AF (ParAF), 65 patients (46%) with persistent AF (PerAF) and 18 patients (13%) with long standing persistent AF (LSPerAF). The distribution of heart failure types was similar between both groups: HFpEF (PFA: 71%, 54 pat.; TA: 75%, 48 pat), HFmrEF (PFA: 21%, 16 pat.; TA: 20%, 13 pat.) and HFrEF (PFA: 8 %, 6 pat.; TA: 5%, 3 pat.). After the 365-days follow-up period we observed no significant difference for the primary end-point between both groups (HR: 0.79, 95% CI 0.35-1.78; p=0.575). In total 57% of the PFA patients and 58% of the TA group were still free from AF. In the PFA group, 70% of the patients with ParAF, 54% with PerAF and 33% with LSPerAF showed no AF recurrence, compared to 68%, 56% and 37% in the TA group, respectively. 
Regarding the secondary end-points there was no significant difference between the groups. The most common periprocedural adverse events were groin complications (PFA group: 3, TA group: 2), one pericardial tamponade in the PFA group managed without the need for surgery, and one transient phrenic nerve injury in the TA group.
In this study, pulsed field ablation and thermal ablation modalities such as cyoballoon ablation and radiofrequency ablation, for pulmonary vein isolation showed comparable results in terms of safety and procedural efficiency in patients with heart failure. Since previous studies have shown that HF patients with AF benefit from PVI using thermal ablation modalities, our results suggest that PVI by PFA might also be a promising ablation method in this vulnerable population.
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