A Fluoroscopy-Free Ablation Workflow for Persistent Atrial Fibrillation Using a Pentaspline Pulse Field Ablation Catheter Guided by Left-Sided Intracardiac Echo Imaging and Electroanatomic Mapping: A Case Series

Background: Pulse field ablation (PFA) is a novel ablation technology with efficacy and safety, potentially making it a preferred ablation technology for persistent atrial fibrillation (AF). There is no optimal procedural workflow established to optimize efficacy, limiting the number of PFA applications and risks of the procedure. Due to the importance of optimal catheter–tissue contact for effective pulse field ablation, a workflow combining superior left atrial intracardiac echo (ICE) imaging and electroanatomic mapping (EAM) is an attractive strategy for PFA of persistent AF. Methods: A detailed procedural workflow was developed for fluoroscopy-free PFA using a pentaspline ablation catheter supported by left atrial ICE and EAM, and a case series of its execution in 30 consecutive patients with persistent AF is presented. All patients underwent pulmonary vein and posterior wall isolation as the index procedure, followed by additional ablation targeting non-pulmonary vein triggers and other inducible atrial arrhythmias. Results: Left atrial ICE imaging and EAM guided procedure resulted in successful isolation of the pulmonary veins and posterior wall in all patients, with additional ablation of spontaneous arrhythmias or non-pulmonary triggers if induced. There were no major complications of the procedure. Average procedure times and short-term efficacy were comparable with reported PFA outcomes using traditional imaging techniques. Conclusions: Fluoroscopy-free PFA guided by left-sided ICE for persistent AF can be performed with superior catheter–tissue contact imaging in a safe manner with a comparable procedural time and short-term efficacy as reported with the use of other imaging modalities.