Pulsed field ablation for pulmonary vein and left atrial posterior wall isolation in persistent atrial fibrillation: a narrative review

Pulsed-field ablation (PFA) is an emerging technique for managing atrial fibrillation (AF). Still, its role in persistent AF (PeAF) with left atrial posterior wall isolation (LAPWI) remains to be defined. The ATHENA registry evaluated 249 PeAF patients across 9 Italian centers using the FARAPULSE PFA system, with 57.6% undergoing LAPWI. Electrical isolation of the posterior wall was achieved in all cases, with a first-pass success rate of 88.8%. The procedure demonstrated a favorable safety profile, with no major periprocedural complications and only a low rate of minor events (2.4%). Secondary endpoints further assessed long-term efficacy and safety, with 16.5% of patients experiencing arrhythmic recurrence beyond the blanking period at a median follow-up of 273 days, corresponding to an overall freedom from recurrence of 83.5%. Complication rates remained low throughout follow-up, with no late-occurring major adverse events reported. Redo procedures were required in 15.3% of LAPWI patients compared with lower rates in the PVI-only group, suggesting a potential benefit of adjunctive posterior wall ablation. These findings support PFA as a feasible, safe, and efficient approach for LAPWI in PeAF, even with fluoroscopy-only guidance.