Clinical outcomes of pulsed field versus radiofrequency ablation, incorporating posterior wall isolation, in persistent atrial fibrillation

BACKGROUND: Persistent atrial fibrillation (AF) remains challenging to treat with catheter ablation. The left atrial posterior wall (PW) may represent an important non-pulmonary vein (PV) substrate; however, randomised trials have not demonstrated improved outcomes with adjunctive PW isolation (PWI), potentially reflecting technical limitations of thermal ablation rather than a lack of mechanistic relevance. Pulsed-field ablation (PFA) is a non-thermal ablation modality that selectively targets myocardial tissue and may enable safer and more consistent PWI. We compared real-world outcomes of PFA and radiofrequency ablation (RFA) for combined PV isolation and PWI in patients with persistent AF. METHODS: 200 consecutive patients (100 PFA and 100 RFA) undergoing combined PVI and PWI were retrospectively followed for up to 12 months. Baseline characteristics were broadly similar; however, PFA patients had lower left ventricular ejection fraction (LVEF) (43.5% (35.5-55.5%) vs 47% (40-58), p=0.01) and higher CHA₂DS₂-VA risk score (3 (2-4) vs 2 (1-3), p=0.01). Primary outcomes were acute procedural success and freedom from recurrent atrial tachyarrhythmia (AT) at 6 and 12 months. RESULTS: PFA achieved near-universal PWI compared with RFA (99% vs RFA: 65%, p