Early Recurrence of Atrial Fibrillation after Pulmonary Vein Isolation: A Comparison Across Different Ablation Techniques

Background: Early recurrence of atrial fibrillation (ERAT) during the 90-day blanking period (BP) following ablation is clinically significant, often resulting in increased symptoms, hospitalizations, and the need for electrical cardioversion. Emerging evidence suggests that certain late-stage ERAT episodes, particularly those near the end of the BP, may correlate with late recurrence of atrial fibrillation (LRAT). Additionally, ERAT is considered a potential marker of inflammatory processes in the atrium following ablation, reflecting cellular responses to tissue injury. This study examines the incidence of ERAT across various ablation techniques, each promoting different mechanisms of cellular injury to achieve pulmonary vein isolation, with the aim of identifying potential differences in effectiveness and implications for patient outcomes.

Methods: This comparative cohort study includes data from 502 patients who underwent their first pulmonary vein isolation between 2019 and 2024. Among them, 85 received Pulsed Field Ablation (PFA), 114 Cryoballoon Ablation, 67 High-Power Short-Duration (HPSD) Ablation, and 236 very High-Power Short-Duration (vHPSD) Ablation. Key outcomes include procedural characteristics and the incidence of ERAT within the first 30 days and across the 90-day BP.

Results: Baseline characteristics and cardiovascular risk profiles were comparable across all groups. During the 90-day BP, patients treated with PFA exhibited a significantly lower incidence of ERAT (5.88%) compared to those treated with Cryoballoon (18.42%), HPSD (23.88%), and vHPSD (13.98%) (p < 0.01). Similarly, ERAT within the first 30 days post-ablation was significantly lower in the PFA group (PFA 2.35%, Cryoballoon 10.48%, HPSD 17.91%, vHPSD 9.32%; p < 0.01). Additionally, procedural time was notably shorter for PFA (50.79 ± 13.96 min) compared to Cryoballoon (90.13 ± 28.65 min), HPSD (109.8 ± 27.28 min), and vHPSD (87.10 ± 30.50 min; p > 0.01).

Conclusion: Patients undergoing PFA demonstrated a significantly lower incidence of ERAT both during the 90-day BP and within the first 30 days post-ablation compared to other ablation techniques. This reduction may be attributed to the unique cellular injury mechanisms of PFA, which appear to provoke a reduced inflammatory response relative to thermal ablation methods. The potentially lower inflammatory reaction associated with PFA could explain the decreased incidence of ERAT observed. Further analysis is warranted to assess the implications of this reduction on long-term outcomes, including late recurrence rates, quality of life, and the potential need for repeat ablation procedures.