Background: 

Pulsed-field ablation (PFA) enables swift pulmonary vein (PV) isolation (PVI). We recently demonstrated feasibility and safety using the novel pentaspline PFA device (5S strategy). In this fluoroscopy-guided PVI strategy, selective PV angiography was used to image the LA/PV anatomy and to guide positioning of the ablation catheter. However, contrast medium (CM) injection can cause renal failure, allergic reactions, and air embolism due to catheter exchanges and injections. 

Objective:

We aimed to streamline the 5S strategy by omitting CM injections and to study (1) procedural metrics as well as (2) safety and (3) rate of silent emboli. 

Methods: 

Between October 2021 and April 2023 patients with drug-refractory AF who underwent PVI using the current pentaspline PFA catheter were enrolled. All procedures have been conducted by experienced operators either with (CM +, n=25) or without (CM- group, n=26) PV angiographical information using CM. Cerebral magnetic resonance imaging (MRI) was systematically performed in all patients on the following days after procedure to assess the rate of silent cerebral emboli (SCE). Acute procedural data and the rate of SCE were analyzed.

Results: 

A total of 51 patients (42% female, 69 ± 10 years old, 31.7% persistent AF) were included in this study. All procedures were completed solely with the PFA system. The CM- group showed significantly shorter procedure, fluoroscopy times, and fluoroscopy dosages (26 ± 6 min vs 36 ± 13 min, p<0.01,  5 ± 2 min vs 7 ± 3 min, p<0.01 and 170 ± 155 μGym2 vs 573 ± 477 μGym2, p<0.01, respectively). Total number of PFA applications per patient was not different between both groups. Postoperative cerebral MRI revealed SCE in 5 patients (19.2%) in the CM- group and 6 patients (24.0%) in the CM+ group (p=0.74). No procedure related complications were noted in both groups. So far, no repeat procedure has been performed in the CM- group.

Conclusion: 

PFA-guided PVI without PV angiograms result in shorter procedure/fluoroscopy metrics without compromising the safety profile. The rate of silent cerebral emboli was not different between both groups.