Staged hybrid convergent procedure versus pulsed field ablation for pulmonary veins and posterior wall isolation in the treatment of atrial fibrillation

Abstract

Abstract Background There are limited effective treatment options for persistent atrial fibrillation (AF) patients, with pulmonary veins (PV) isolation alone being considered suboptimal for many patients. Hybrid convergent ablation has been shown to improve clinical outcomes when compared to an endocardial-only radiofrequency (RF) strategy. Pulsed field ablation (PFA) has recently gained growing interest for its efficacy and safety profile in PV and posterior wall (PW) ablation. Objectives To compare clinical outcomes of hybrid convergent RF ablation versus endocardial PFA for PV and PW isolation in patients with persistent AF. Methods From July 2022, 86 persistent AF consecutive patients, receiving endocardial PFA of PV and PW (PFA group, N = 44) or receiving hybrid convergent RF ablation (Hybrid group, N = 42) at our institution were enrolled. Recurrence was defined as any atrial tachyarrhythmia following the 3-month blanking period. Results No differences were found between PFA and Hybrid groups regarding age (PFA 66.0±7.4 years vs Hybrid 63.9±10.6 years; p=0.193) and left atrial volume index (PFA 45.5 [36.7-57.2] ml/m² vs Hybrid 45.0 [39.2-59.7] ml/m²; p=0.920). Differences regarding left ventricular ejection fraction were borderline significant among groups (PFA 55.0 [49.5-62.0]% vs Hybrid 60.5 [52.3-65.0]%; p=0.048), both showing an overall normal LV function. There were no significant differences regarding AF duration (PFA 38.0 months [IQR: 19.2 to 99.0 months] vs Hybrid 70.0 months [IQR: 46.0 to 118.0 months]; p = 0.063). Redo ablation patients’ rate was higher in the hybrid group (PFA n=16, 36.4% vs Hybrid n=28, 66.6%; p<0.001). Procedure duration was Ionger in the hybrid group (179.9±60.1 minutes) compared to PFA endocardial ablation (PFA 106.2±30.7 minute; p<0.01). After a median follow-up of 233.0 [179.0–331.8] days, there was no difference in atrial tachyarrhythmias recurrence rate (PFA n=11, 25.0% vs Hybrid n=10, 23.8%; p=0.897); no difference in the antiarrhythmic drug use rate was found (PFA n=24, 54.5% vs Hybrid n=19, 45.2%; p=0.388). Conclusions PFA of PV and PW, compared with the hybrid convergent ablation strategy, is an endocardial-only, less invasive, and faster procedure. 6-month rhythm outcomes were similar in both groups.