Impact of obesity on procedural safety and 1-year outcomes after pulsed-field ablation for atrial fibrillation

AIMS: Obesity is associated with atrial fibrillation (AF), atrial remodelling, and cardiometabolic comorbidities. Whether baseline body mass index (BMI) influences procedural safety and effectiveness of pulsed-field ablation (PFA) remains uncertain. We evaluated the association of baseline BMI with procedural characteristics, periprocedural safety, and 1-year arrhythmia recurrence after first-time PFA for AF. METHODS AND RESULTS: FRANCE-PFA is a nationwide registry including consecutive patients undergoing first-time AF ablation with a pentaspline PFA catheter. Patients with available BMI were categorized as <25, 25 to <30, 30 to <35, or ≥35 kg/m2. Periprocedural complications and 1-year atrial arrhythmia recurrence were assessed across BMI categories. Among 5223 patients, BMI was available in 4573 (87.6%). Higher BMI was associated with greater cardiometabolic burden, more persistent AF, larger atria, and more extensive ablation strategies, including fewer pulmonary vein isolation-only procedures and more additional lesion sets (all P < 0.001). Periprocedural complications remained infrequent (1.0%), with no significant difference across BMI categories. At 1 year, recurrence was driven mainly by AF type rather than obesity. Within paroxysmal and non-paroxysmal AF, recurrence rates were comparable between patients with BMI < 35 and ≥35 kg/m2 (13.8% vs. 9.1% and 22.9% vs. 23.3%, respectively; log-rank P = 0.925). Severe obesity was not associated with recurrence after multivariable adjustment (HR, 0.86; 95% CI, 0.65-1.14; P = 0.299), with similar findings when BMI was analysed continuously. CONCLUSION: In this nationwide PFA cohort, higher BMI identified a more advanced AF phenotype and more extensive ablation strategies but was not independently associated with periprocedural complications or 1-year arrhythmia recurrence.