Impact of left atrial posterior wall isolation using pulsed-field ablation in patients undergoing repeat catheter ablation for atrial fibrillation

BACKGROUND: Durable pulmonary vein isolation (PVI) is the primary objective of catheter ablation of atrial fibrillation (AF). In repeat procedures, posterior wall isolation (PWI) is the primary adjunctive target, particularly with pulsed-field ablation (PFA), although evidence supporting its clinical benefit remains limited. OBJECTIVE: This study aimed to compare procedural characteristics, safety, and efficacy of 2 ablation strategies in repeat AF ablation: redo PVI alone (PVI group) vs redo PVI with adjunctive PWI (PVI+ group). METHODS: Consecutive patients undergoing redo PVI at 2 centers, with 1-2 reconnected pulmonary veins identified on preablation mapping, were enrolled. PFA or radiofrequency ablation was used in the PVI group, whereas only PFA was used in the PVI+ group. Propensity score matching (1:1 ratio) was performed. RESULTS: A total of 122 patients were included in each group (median age 67 years; 30% female). Median left atrial diameter was 41 mm [37-46], and 46% had persistent AF. Procedure duration, left atrial dwell time, and fluoroscopy time were significantly shorter in the PVI group (all P < .001). Procedural success was 100% in both groups. 1 major complication occurred in each group (0.8%). At a median follow-up of 370 days, arrhythmia-free survival was 69% in the PVI group and 72% in the PVI+ group (P = .517). CONCLUSION: Redo PVI with or without adjunctive PWI is safe and effective, with comparable arrhythmia-free survival. Adjunctive PWI prolongs procedural duration without improving outcomes. Randomized trials are required to clarify its role.