Novel pulsed-field ablation technology for pulmonary vein isolation in patients with atrial fibrillation: preliminary experience from a large multicenter clinical practice
Authors: Iacopino S , Dello Russo A , Tundo F , Solimene F , Bianchi S , Casella M , Rossillo A , Themistoclakis S , Majocchi B , Filannino P , Cipolletta L , Schillaci V , Bisignani A , Malacrida M , Tondo C 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Complete electrical pulmonary vein isolation (PVI) by thermal energy sources is a well-established ablation strategy of atrial fibrillation (AF). Recently, a non-thermal ablation approach by means of irreversible cellular electroporation has been made available for clinical use.

Purpose
We report the preliminary experience of a new pulsed-field ablation (PFA) system in the context of AF ablation in a multicenter Italian setting.

Methods
All consecutive patients (pts) undergoing AF ablation with PFA at 7 Italian centres were included. Protocol-directed PVI was delivered using 2000 V with eight applications per vein, that is, four applications each in the basket and flower poses. Applications were delivered in pairs at any given catheter position, rotating by ≈30–40° after the first two applications in each configuration. Additional lesions were performed at the operator’s discretion. The ablation endpoint was PVI as assessed by entrance and exit block. Data are reported as median [IQ range].

Results
With a median of 32[25-38] pts treated per center, a total of 205 cases were included (n=150 73.2%, paroxysmal AF, n=55, 26.9% persistent AF). Of them 187 (91.2%) were de novo cases, whereas 18 (8.8%) were redo cases. A mapping system was used in 55 (21.5%) procedures and an intracardiac echocardiography in 65 (31.7%) cases. The number of PFA applications to reach PVI was 32[32-36]. Procedural parameters were: fluoroscopy time = 16[12-22] min, skin-to-skin time = 60[55-85] min, support time (preparation plus skin-to-skin) =75[64-95] min, lab occupancy time was 97[75-120] min and PFA LA dwell time was 23[20-28] min. The first pass isolation (FPI) rate per vein was 99.6% resulting from 202 patients (98.5%) with FPI. At the end of the procedure, PVI was achieved in all pts (100%) using only PFA. Additional PFA delivery outside PVs was performed in 19% (n=39) of the cases, mostly at the posterior wall area only (n=34, 87%), requiring 16[12-24] PFA deliveries. All the additional lesion sets were validated through differential pacing and/or 3D mapping. The learning curve was extremely fast. After only 5 cases time to PVI and total support time have significantly improved, whereas we did not notice any additional improvement after 10 or 20 cases (LA dwell time: 27[22-32] min during the first 5 cases vs 23[19-27] min after the first 5 cases, p=0.0172; support time: 100[65-120] min vs 75[65-90] min, p=0.0181, respectively). In 13 (6.3%) cases a transient bradycardia or asystole occurred after the first PFA application requiring temporary high-output pacing. No major procedure-related adverse events were reported.

Conclusion
In this first multicentric experience, the novel PFA system proved to be safe and effective in both paroxysmal and persistent AF patients. The learning curve seems to be very fast according with procedural parameters.