Repeat procedures after pulsed field ablation for atrial fibrillation: tertiary centre experience and meta-analysis of observational studies

BACKGROUND: Limited real-world data exist regarding pulmonary vein (PV) and posterior wall (PW) durability after index pulsed field ablation (PFA) for atrial fibrillation (AF) in patients undergoing repeat procedure. METHODS: We performed a single-centre retrospective observational study of consecutive patients who underwent repeat procedure for arrhythmia recurrence after index PFA for AF and a meta-analysis of published observational studies. All patients underwent index PV ± PW isolation with Farapulse/Farawave (Boston Scientific, US). Endpoints were incidence of repeat procedure and durability of PVI and PW ablation at repeat procedure. A meta-analysis was also performed evalutaing these endpoints following PFA with the same pentaspline catheter. RESULTS: Out of 751 index PFA procedure, 50 patients underwent repeat procedure (6.7%) at median 6.8 months (IQR 3.2–10.1). Arrhythmia recurrence was 48% AF, 36% AT/AFL and 16% both. Persistent AF at index ablation was associated with repeat procedure (p = 0.03). In 48 patients, PVs were durably isolated in 38%. Most common reconnection was RSPV (44%; 21/48), LSPV (40%; 19/48), RIPV (25%; 12/48) then LIPV (21%; 10/48). Superior PVs were more commonly reconnected than inferior PVs (p = 0.005). PW reconnection occurred in 70% (16/23). Meta-analysis of 6 further studies (n = 708) showed repeat procedure rate of 8.8% (95%CI 0.05–0.11). PVs were reconnected in 57% (95%CI 0.48–0.65) and PW reconnected in 55% (95%CI 0.39–0.71). CONCLUSIONS: These real world data and meta-analysis show limited PV and PW durability in patients with arrhythmic recurrence undergoing repeat procedure after PFA for AF. Additional procedural strategies are needed to enhance lesion durability from PFA.