Work

Pulsed-field vs radiofrequency ablation for posterior wall isolation in persistent atrial fibrillation: A propensity-matched outcome analysis

Year: 2026

Type: article

Abstract: Background Left atrial posterior wall isolation (LAPWI) is increasingly used as an adjunct to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PerAF) despite the absence of strong evidences, but the optimal ablation modality remains uncertain. Objective Our study focuses on procedural differences between PFA and RF when LAPWI is performed, rather than on the efficacy of LAPWI itself. Pulsed-field ablation (PFA) may offer advantages over radiofrequency (RF) due to its non-thermal mechanism and improved tissue selectivity. Methods In this single-center study, 92 patients with PerAF and posterior low-voltage substrate identified via high-density mapping were treated with either PFA (n=46) or RF ablation (n=46) for PVI plus LAPWI. Remapping was performed to confirm complete electrical isolation. Groups were 1:1 propensity score–matched for analysis. Results The primary endpoint was freedom from any sustained atrial arrhythmia (>30 seconds) at 12-month follow-up, assessed via structured Holter-ECG monitoring at 3, 6, and 12 months. Complete LAPWI was achieved in 100% of PFA and 95.7% of RF patients. Procedure time was significantly shorter with PFA (68.2min [44–91] vs 86.8min [58–118], p<.05). Arrhythmia-free survival at 12 months was similar between groups (58.7% vs 52.2%, p=0.57, RR 1.13, 95% CI 0.78–1.63). Multivariable Cox regression identified LA diameter, BMI >30, and hypertension as independent predictors of arrhythmia recurrence. Complication rates were low and comparable. Conclusion In patients with PerAF and posterior low-voltage substrate, PFA and RF yielded similar arrhythmia-free survival at one year. PFA was associated with shorter procedure times and high rates of posterior wall isolation.

Source: Heart Rhythm O2

DOI: 10.1016/j.hroo.2025.12.023