Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

Pulmonary vein isolation (PVI) alone is insufficient to treat many patients with persistent atrial fibrillation (PerAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of efficacy, perhaps limited by the difficulty in achieving lesion durability amid concerns of esophageal injury. To compare the safety and effectiveness of PVI+ LAPW ablation versus PVI in patients with PerAF using pulsed-field ablation (PFA). In a retrospective analysis of the MANIFEST-PF registry, we studied consecutive PerAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of ≥30 seconds. Safety outcomes included the composite of acute and chronic major adverse events (MAE). Of the 547 PerAF patients who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years, p=0.08), had a lower CHA2DS2-VASc score (2.3±1.6 vs 2.6±1.6, p=0.08), more likely to receive electroanatomical mapping (48.1% vs 39.0%, p=0.07) and ICE imaging (46.1% vs 17.1%, p<0.001). The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI+LAPW: 66.4% [95% CI 57.6-74.4%] vs PVI: 73.1% [95% CI, 68.5-77.2%], p=0.68) and propensity-matched cohorts (PVI+LAPW: 71.7% vs. PVI: 68.5%, p=0.34). There was also no significant difference in MAE between the groups (2.2% vs. 1.4%, respectively, p=0.51). In PerAF patients undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months.