Combined Pulsed Field and Radiofrequency Ablation for Coexisting Atrial Tachycardia During or After Atrial Fibrillation Ablation. Interventional and Clinical Outcomes

BACKGROUND: Patients with atrial fibrillation (AF) may develop atrial tachycardias (ATs) post-ablation or intraprocedurally, especially those with persistent AF or fibrotic substrates. Managing these arrhythmias remains challenging in the pulsed field ablation (PFA) era. METHODS: This prospective study included 56 consecutive patients (mean age 71 ± 8.5 years, 42.9% prior AF ablation) with non-paroxysmal AF or AT and history of AF, who exhibited ≥ 1 left-sided AT during ablation. Targeted intervention of the AT mechanism was performed alongside a prespecified prophylactic lesion set (PPLS), comprising pulmonary vein isolation and posterior wall (PW) ablation via the pentaspline PFA catheter, mitral isthmus (MI) ablation using combined radiofrequency ablation (RFA) and PFA, and cavotricuspid isthmus (CTI) ablation with RFA. RESULTS: A mean of 1.9 ± 0.9 ATs was identified per patient (48.1% macro-reentry, 20.2% localized reentry, 30.8% unmappable). Acute ablation success at all target sites was 100%. Over a mean follow-up of 20.6 ± 6.6 months (minimum 12), sinus rhythm was maintained in 78.6% of patients after the index procedure and 87.5% after repeat. In nine patients undergoing reintervention, durability was 97.2% for pulmonary veins, 89% for MI linear lesions, and 100% for PW and CTI. Pre-ablation clinical AT (35.7% of patients) significantly predicted non-recurrence (p = 0.021). Interestingly, the inability to achieve successful AT mapping (37.5% of patients) did not negatively influence the clinical outcome. CONCLUSION: In patients with an AF history and left-sided ATs, a PPLS combined with targeted AT mapping and ablation demonstrates excellent outcomes. Integrating RFA and PFA for MI ablation ensures both acute success and high long-term durability.