https://doi.org/10.1007/s00392-025-02625-4
1Agaplesion Markus Krankenhaus Medizinische Klinik III - CCB Frankfurt am Main, Deutschland
Background: The cornerstone of AF catheter ablation is pulmonary vein isolation (PVI) using either point-by-point radiofrequency ablation (RF) or single-shot devices like the cryoballoon (CB). Since CB ablation requires circumferential contact with the PV ostium, isolating a left common pulmonary vein (LCPV) can be challenging due to its size and anatomy. For this reason, many operators prefer point-by-point ablation for LCPVs. Pulsed field ablation (PFA) with the pentaspline catheter is a non-thermal technology targeting specifically myocardial tissue. Available in 31mm and 35mm sizes, it can effectively treat even large PV ostia, making it a potential single-shot solution for LCPV ablation.
Purpose: The aim of this study is to describe our experience and approach with PFA in LCPVs and to report lesion durability from repeat procedures.
Methods: Consecutive AF patients with an LCPV who underwent PFA-PVI between May 2021 and May 2024 were enrolled. We report procedural data including different approaches depending on LCPV configuration, long-term follow-up and results from repeat procedures. We aim to asses feasibility, efficacy and eventual benefits of PFA for this particular anatomical variant. Success was defined as no recurrence of atrial tachyarrhythmia after a 3-month blanking period.
Results: This study included 62 patients (40% female, 53% with paroxysmal AF (PAF), mean age 70±2.4 years). Mean atrial diameter and EF were 41±2.3mm and 61±2.3% respectively. Mean LCPV diameter was 27±1.5 mm. Mean procedural and fluoroscopy times were 37±4 min and 8.5±1 min, respectively. Successful PVI using solely PFA was achieved in all PVs. In 6 patients, additional ablation beyond PVI was performed.
Complication rate was 4.8% (3/62) with one coronary air embolism, one access site complication that required intervention and one cardiac tamponade that required pericardiocentesis.
Following fluoroscopic evaluation, a 35mm device was selected in 38 cases (61%). For 19 LCPVs, the two branches were treated separately. When the LCPV was treated as a single vein with the standard number of applications, the operator opted for additional applications in 25.6% of the cases (11/43).
Mean follow-up time was 305 days with a recurrence free survival after 1-year of 80%; with 88% in patients with PAF and 73% in patients with persistent AF (p=0.051). We recorded 7 repeat procedures after a mean time of 465 days. The total number durable isolated non-LCPVs was 11/14 (78.6%) while only 3/7 (42.9%; p=0.156) LCPVs showed durable isolation.
Conclusion: PFA for LCPV demonstrated a good safety profile, short procedure times, high rate of acute isolations and a favorable 1-year follow-up. However, the high rate of reconnections in LCPVs during repeat procedures indicates that an optimized strategy for this challenging anatomic variant still has to be found.