Pulsed Field vs Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation
Authors: Vivek Y. Reddy, Moussa Mansour, Hugh Calkins, Andre d'Avila, Larry Chinitz, Christopher Woods, Sanjaya K. Gupta, Jamie Kim, Zayd A. Eldadah, Robert A. Pickett, Jeffrey Winterfield, Wilber W. Su, Jonathan W. Waks, Christopher W. Schneider, Elizabeth Richards, Elizabeth M. Albrecht, Brad S. Sutton, Edward P. Gerstenfeld, William Whang, Vivek Reddy, Jacob Koruth, Srinivas Dukkipati, David DeLurgio, Anshul Patel, Jose Osorio, Anil Rajendra, Gustavo Morales, Benjamin D'Souza, John Bullinga, Frank Cuoco, Darren Sidney, Marcos Daccarett, John Harding, Robert Sangrigoli, Robert Pickett, Daniel Kaiser, Andrea Natale, Joseph Gallinghouse, Sanjaya Gupta, Daniel Steinhaus, Moussa Mansour, Kevin Heist, Nathan Van Houzen, Jeffrey Winterfield, Michael Field, Tom McElderry, William Maddox, Larry Chinitz, Douglas Holmes, Hugh Calkins, David Spragg, Zayd Eldadah, Sung Lee, Athanasios Thomaides, Michael Mangrum, Douglas Gibson, Nicholas Olson, Christopher Woods, Amir Schricker, Christopher Ellis, Gregory Michaud, Edward Gerstenfeld, Joshua David Moss, Thomas Dewland, Stavros Mountantonakis, Nicholas Skipitaris, Kabir Bhasin, Wilber Su, Michael Zawaneh, Jonathan P. Weiss, Pasquale Santangeli, David Lin, Jamie Kim, Connor Haugh, Matthew Latacha, Chinmay Patel, Michael Link, Kenneth Ellenbogen, Jayanthi Koneru, Blair Halperin, D. Randolph Jones, Andre D'Avila, Jonathan Waks, Kapil Kumar
Journal: Journal of the American College of Cardiology (2024)

The ADVENT randomized trial revealed no significant difference in 1-year freedom from atrial arrhythmias (AA) between thermal (radiofrequency/cryoballoon) and pulsed field ablation (PFA). However, recent studies indicate that the postablation AA burden is a better predictor of clinical outcomes than the dichotomous endpoint of 30-second AA recurrence. The goal of this study was to determine: 1) the impact of postablation AA burden on outcomes; and 2) the effect of ablation modality on AA burden. In ADVENT, symptomatic drug-refractory patients with paroxysmal atrial fibrillation underwent PFA or thermal ablation. Postablation transtelephonic electrocardiogram monitor recordings were collected weekly or for symptoms, and 72-hour Holters were at 6 and 12 months. AA burden was calculated from percentage AA on Holters and transtelephonic electrocardiogram monitors. Quality-of-life assessments were at baseline and 12 months. From 593 randomized patients (299 PFA, 294 thermal), using aggregate PFA/thermal data, an AA burden exceeding 0.1% was associated with a significantly reduced quality of life and an increase in clinical interventions: redo ablation, cardioversion, and hospitalization. There were more patients with residual AA burden <0.1% with PFA than thermal ablation (OR: 1.5; 95% CI: 1.0-2.3; P = 0.04). Evaluation of outcomes by baseline demographics revealed that patients with prior failed class I/III antiarrhythmic drugs had less residual AA burden after PFA compared to thermal ablation (OR: 2.5; 95% CI: 1.4-4.3; P = 0.002); patients receiving only class II/IV antiarrhythmic drugs pre-ablation had no difference in AA burden between ablation groups. Compared with thermal ablation, PFA more often resulted in an AA burden less than the clinically significant threshold of 0.1% burden. (The FARAPULSE ADVENT PIVOTAL Trial PFA System vs SOC Ablation for Paroxysmal Atrial Fibrillation [ADVENT]; NCT04612244)