Thermal Versus Pulsed Field Ablation for Atrial Fibrillation in a Real-World Scenario

Background
Pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). However, the optimal method for PVI remains uncertain. Thermal ablation techniques, such as radiofrequency ablation (RFA) and cryoablation, are commonly used approaches. Pulsed field ablation (PFA) has emerged as a promising non-thermal alternative based on electroporation, offering the advantage of more selectively targeting cardiac tissue while sparing surrounding structures. The recent ADVENT trial demonstrated that PFA is feasible and effective compared to traditional thermal ablation methods in a controlled-trial setting.

Aim
The aim of this study was to compare procedural data, complications and outcome of PFA with thermal ablation methods under realistic conditions in a real-world scenario.

Methods
All de novo PVIs performed at our center between September 2021 and June 2023 using PFA, RFA, and cryoablation were analysed. Only patients who received exclusively de novo PVI were included. Ablation strategy and technique were at operators’ discretion but consisted of electrical PV isolation in all cases.

Results
A total of 472 procedures were analysed. 382 patients received thermal ablation (168 RF-PVI, 214 Cryo-PVI) and 90 patients received PFA-PVI. In the thermal ablation group (61.3% male; 65.8 ±12.0 y) 169 patients (44.2%), and in the PFA group (68.9% male; 67.4 ± 11.0 y) 61 patients (67.8%) suffered from persistent AF. The procedure time was significantly shorter using PFA compared to thermal energy (thermal: 80.6 ± 29.4 min, PFA: 57.8 ± 18.5 min, p<0.0001). Overall complication rates were comparable between groups (thermal: n=20, 5.2%; PFA: n=5, 5.6%, p=0.9) and no deaths occurred in either group. After a mean follow-up of 304.9 days, freedom from any atrial arrhythmia was observed in 70.8% of patients with PAF in the thermal ablation group, compared to 84.0% in the PFA group. However, this difference was not statistically significant (p=0.2, HR 0.53, 95% CI 0.24–1.15). For patients with persAF freedom from any atrial arrhythmia was similar between groups, with 66.0% in the thermal ablation group and 68.4% in the PFA group (p=0.6, HR 0.87, 95% CI 0.52–1.46).

Conclusion
PFA is a safe and effective method for PVI with comparable success rates to thermal ablation. The main advantage consists of reduced procedure time compared to thermal ablation even under non-controlled real-world conditions.






Figure 1: Kaplan-Meier analysis