Background: Pulsed field ablation (PFA) has recently been introduced as a novel ablation technology for atrial fibrillation (AF). However, multi-center data regarding acute procedural efficacy and safety is sparse.

Objective: To investigate acute procedural success and safety in patients undergoing PFA for the treatment of AF in a multicenter registry.

Methods: Consecutive paroxysmal and persistent AF patients underwent PFA-based catheter ablation using a multispline catheter. PFA-based ablation procedures, including first and repeat ablation procedures, were performed with and without additional 3D electroanatomical mapping. Procedural parameters, acute success and in-hospital safety were assessed. 

Results: A total of 154 patients undergoing PFA in 5 German centers were included in the study. Patients suffered from paroxysmal AF (n= 55; 36%), persistent AF (n=93; 60%) and consecutive atrial tachycardias (AT) due to previous catheter ablation (n=6; 4%). Mean age was 68 ± 12 years, median CHA2DS2-VASc Score was 3 (Q1-Q3: 2-4), mean left atrial diameter was 43 ± 6 mm and 111 of 154 (72%) patients had a normal left ventricular ejection fraction.

Of all PFA procedures, 130 (84%) were index ablation procedures with sole isolation of pulmonary veins (PVI) and 24 (16%) were repeat procedures (including re-PVI and ablation of consecutive AT). The median total procedure and left atrial (LA) PFA times were 90 (Q1-Q3: 73-116) and 33 (Q1-Q3: 24-53) minutes, respectively. Mean total fluoroscopy and LA PFA fluoroscopy times were 20.2 ± 8.7 and 12.1 ± 5.5 minutes. Acute pulmonary vein (PV) reconnection following primary PVI and the initial set of PFA-applications was found in 20 of 130 (15%) patients, requiring additional ablation. Finally, successful PVI was achieved in all patients.

Three-dimensional electroanatomical mapping was performed in 151 of 154 (98%) patients. The use of ultra-high-density (UHDx) mapping systems was associated with higher procedure durations (143 ± 39 minutes vs. non-UHDx 85 ± 27 minutes; P <0.0001). Additional PFA lesion sets (including LA posterior wall isolation, anterior ablation, mitral isthmus ablation) were applied in 17 of 154 (11%) patients.

Complications occurred in 6 of 154 (3.8%) patients including 3 groin site complications, 2 pericardial tamponades and 1 transient coronary spasm without sequela. There was no transient ischemic attack and no stroke reported. 

Conclusion: In this first real-world multicenter registry, PFA applied in patients with atrial fibrillation demonstrates high acute procedural success rates and a favorable safety profile.