PVI Durability After PFA or RFA in Persistent-AF

BACKGROUND: Durable pulmonary vein isolation (PVI) is the primary objective of atrial fibrillation (AF) ablation, yet reconnections are common and non-PV mechanisms may drive recurrence in persistent AF. OBJECTIVES: This study sought to compare PVI durability and arrhythmia recurrence between pulsed field ablation (PFA) and radiofrequency ablation (RFA) in persistent AF patients. METHODS: Persistent AF patients undergoing PVI were prospectively enrolled, with a mandatory remapping procedure performed after 6 months regardless of recurrence. RFA was used in phase 1 (n = 30) and PFA was used in phase 2 (n = 30). Patients were followed with 7-day Holter electrocardiograms after 3, 6, and 12 months. Primary and secondary endpoints were PVI durability and arrhythmia recurrence. RESULTS: Of 60 enrolled patients, 51 underwent the mandated remapping procedure after a median of 7.2 months (mean age 68 years; 82% male). PVI was durable in 78 of 102 PVs (76%) with RFA and in 82 of 104 PVs (79%) with PFA (adjusted OR: 1.20; 95% CI: 0.37-3.88; P = 0.77), with lowest durability in the right superior PV (PFA 72%; RFA 69%). All PVs were durably isolated in 26 patients (51%). Of 26 patients (51%) with durably isolated PVs, 9 (35%) experienced AF recurrence prior to the remapping procedure. Of 25 patients (49%) with reconnected PVs, 7 (28%) experienced AF recurrence. At 1-year follow-up, freedom from recurrence after mandated redo procedure was 70% with no difference between the 2 ablation technologies (adjusted HR: 0.80; 95% CI: 0.24-2.64; P = 0.71). CONCLUSIONS: In patients with persistent AF, PFA demonstrated PVI durability comparable to RFA. Arrhythmia recurrence occurred in a substantial proportion of patients with durable PVI, suggesting a role for non-PV mechanisms.