Pulsed Field Ablation for Persistent Atrial Fibrillation

To the Editor: In the AVANT GUARD trial, Wazni et al. (June 25 issue) 1 report that pulsed field ablation (PFA) was superior to antiarrhythmic drugs as the initial treatment for persistent atrial fibrillation (hazard ratio for composite treatment failure, 0.46). However, safety related to this approach requires scrutiny. The trial was paused after six procedure-related strokes occurred. Before the trial pause, stroke occurred in 3.3% of the patients (6 of 183) assigned to the PFA group, a far greater percentage than the 0 to 0.1% observed in previous studies. 2,3 After resumption of the trial, the protocol excluded patients with a . . .