Pulsed field ablation prevents left atrial restrictive physiology after posterior wall isolation in patients with persistent atrial fibrillation

Extensive ablation, including posterior wall isolation (PWI) is advocated for radiofrequency ablation (RFA) of persistent atrial fibrillation (peAF) to decrease the high recurrence-rates reported when only pulmonary vein isolation (PVI) is performed. 1 Sharma E. Varley A. Osorio J. et al. Procedural Trends in Catheter Ablation of Persistent Atrial Fibrillation: Insights From the Real-AF Registry. Circ Arrhythm Electrophysiol. 2023; 16e011828 Google Scholar However, extensive RFA of the posterior wall may cause fibrosis and "stiff-left-atrium" syndrome. 2 Lee J.H. Kwon O.S. Yu H.T. et al. Risk Factors for Stiff Left Atrial Physiology 1 Year After Catheter Ablation of Atrial Fibrillation. Front Physiol. 2021; 12740600 Google Scholar 3 Gibson D.N. Di Biase L. Mohanty P. et al. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors. Heart Rhythm. 2011; 8: 1364-1371 Google Scholar Magnetic resonance imaging after PVI demonstrates that edema and delayed enhancement are permanent after RFA, but short-lasting after pulsed field ablation (PFA). PV antral strain and LA emptying decline permanently after RFA but recover after PFA. 4 Nakatani Y. Sridi-Cheniti S. Cheniti G. et al. Pulsed field ablation prevents chronic atrial fibrotic changes and restrictive mechanics after catheter ablation for atrial fibrillation. Europace. 2021; 23: 1767-1776 Google Scholar We studied, for the first time, the effects of PFA on the mechanical function of the LA in patients undergoing PWI. The study was approved by our Institutional Review Board; all patients provided informed consent.