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Does hemolysis matter after pulsed field ablation for atrial fibrillation? Insights from the Best Ablate Registry

Year: 2025

Type: article

Abstract: Background Pulsed field ablation (PFA) has emerged as a novel nonthermal modality for atrial fibrillation (AF) ablation, offering tissue selectivity and procedural safety. However, emerging data have raised concerns about hemolysis-related biomarker shifts and potential renal failure following PFA. Objective This study aimed to evaluate biomarker-defined hemolysis and incidence of acute renal injury following PFA in patients undergoing AF. Methods In this prospective observational study, 84 patients with paroxysmal or persistent AF undergoing PFA using either the Affera or PulseSelect system were enrolled. Paired venous blood samples were obtained before and 24 hours after the procedure. Biomarkers of hemolysis (lactate dehydrogenase (LDH), haptoglobin, hemoglobin, and bilirubin), renal function parameters (serum creatinine, urea and electrolytes), and cardiac enzymes (high-sensitivity cardiac troponin, NT-pro-BNP) were systematically analyzed. Clinically significant hemolysis was defined as a post-procedural haptoglobin concentration below 0.04 g/L or a combination of indirect bilirubin greater than 1.5 times baseline and LDH more than twice baseline. Multivariable linear regression and mediation analyses were performed to identify procedural predictors of biomarker changes and to explore the potential mediating role of myocardial injury. Results Significant post-procedural changes were observed in biomarkers of hemolysis, including a reduction in haptoglobin (–0.17 ± 0.21 g/L, p < 0.001), an increase in LDH (+43.32 ± 79.98 U/L, p < 0.001), and bilirubin concentrations (p < 0.001). No patient met the predefined criteria for clinically significant hemolysis. Acute kidney injury of stage 1, without oliguria, was observed in 3 patients (3.6%). Cardiac biomarker analysis revealed a substantial rise in high-sensitivity troponin (+1151.7 ± 750.8 ng/L, p < 0.001), while NT-pro-BNP decreased significantly post-ablation (p < 0.001). The total number of PFA applications independently predicted changes in both LDH and haptoglobin. Conclusion In our study, PFA for AF was associated with an increase in hemolytic parameters, without significant short-term renal impact or occurrence of clinically significant hemolysis. Hemolysis appears to be influenced by both lesion burden and myocardial injury, highlighting the need for further investigation into the long-term clinical relevance of biomarker-defined hemolysis in PFA-treated patients.

Source: Heart Rhythm O2

DOI: 10.1016/j.hroo.2025.11.010