Impact of early recurrences on late recurrences after pulmonary vein isolation with pulsed field ablation. A subanalysis from the EU-PORIA multicenter international registry

Abstract

Abstract Background Early recurrences of atrial tachyarrhythmia (ERAT) are commonly observed after pulmonary vein isolation (PVI) with thermal energies. ERAT during the 90-day blanking period (BP) should not be considered therapy failure as the cardiac tissue is still healing and the long-term benefit of PVI may not be immediately apparent. With the introduction of pulsed field ablation (PFA), a non thermal, myocardial-specific ablation technology for atrial fibrillation (AF), the significance of ERAT following PVI is unclear. Methods EU-PORIA (EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation), a multicentre international registry, collected data from 1233 patients treated with the pentaspline PFA catheter. For the current analysis, patients with a previous AF ablation procedure, patients treated with lesions beyond PVI, and patients without complete follow up data (during and following the BP) were excluded. The rate and significance of ERAT following PFA PVI were analysed. Results This subanalysis included 1011 patients (38% female, 66±11 years old, 64% paroxysmal atrial fibrillation [PAF]). ERATs were recorded in 178/1011 (18%) of patients (16% in PAF and 21% in persAF, p=0,021). Notably, ERAT patients were older (67,1±11,4 Vs 65,4±10,9, p=0,015) and had a higher median CHA2DS2-VASc Score (2,5 [IQR:1-4] Vs 2 [IQR:1-3]; p=0,019). The 35-mm catheter was more often used in ERAT patients (48/178(27%) Vs 148/833(18%) – p=0,005). At a median follow-up of 365 days (IQR 347-390), 100/178(56%) of patients with ERAT had documented late recurrence (LR), compared to only 147/833(18%) of patients in sinus rhythm throughout BP (p<0,001). Kaplan Meier estimates for overall freedom from AF/AT outside of the BP was 77% at one year for all patients. Patients with ERAT had a significantly lower freedom from AF/AT compared to patients with no ERAT (42% vs 84%, log-rank p<0,001). The absence of ERAT was associated with long-term success independent of the type of AF (41% Vs 88% in PAF, 43% vs 74% in persistent AF; p<0,001 for both). Among ERAT patients, no additional predictors for LR were identified. Conclusions In this large multicentre international registry, early recurrence of atrial tachyarrhythmia following PFA PVI were recorded in 18% of patients. ERAT was associated with late recurrences in the majority of cases, independent of AF type. The need for a blanking period following non thermal energy ablation for atrial fibrillation should be further questioned.