Background: Pulsed field ablation (PFA) is a novel ablation energy source with promising safety and efficacy advantages compared to standard ablation technologies. Vascular access complications are the most common complications following atrial fibrillation (AF) ablation. We aimed to develop a safe, effective and fast pulmonary vein isolation (PVI) utilizing a single shot PFA catheter via a single femoral vein puncture and a venous closure system approach.

Methods: Forty-eight consecutive AF patients underwent first-time PVI via PFA under deep sedation. A single ultrasound guided femoral vein puncture and a single transseptal puncture was utilized for left atrial (LA) access. Atropine (1 mg) was administered intravenously at the beginning of the procedure. After pulmonary vein (PV) angiography eight pulse trains (2 kV/2.5 sec, bipolar, biphasic, 4x basket/4x flower configurations) were delivered to each PV. Extra pulse trains in the flower configuration (2x/vein) were added at the posterior aspect of the PVs for wide antral circumferential ablation (WACA), see Figure 1. A venous closure system was utilized on the single access site. A Donati suture was performed. The pressure bandage was removed after 1 h.

Results: Forty-eight patients (mean age: 64±11 years) presented with paroxysmal (58 %) or persistent AF (42 %). A total of 192 PVs were identified and successfully isolated via PFA (100 %). A mean of 40 pulse trains for PVI and WACA have been applied. The mean procedural time was 27±7 minutes, the mean catheter dwell time was 14±6 minutes and the mean fluoroscopy time was 6±2 minutes. One patient (2 %) experienced a transient phrenic nerve paralysis which recovered until the end of the procedure. Two patients (4 %) experienced a superficial bleeding of the puncture site which was treated by a figure of eight suture. No transfusion or additional intervention was necessary. No severe hematoma, pericardial effusion, tamponade or vagal response occurred.

Conclusion: Simplified PFA PVI procedures using a single venous puncture and single transseptal puncture approach resulted in a 100 % rate of acute PVI and an extraordinary fast procedure and short LA dwelling time. The rate of periprocedural complications was low.

Figure 1: Case example of PFA with single transseptal puncture. PFA catheter located at the right superior pulmonary vein (left picture, RAO view) and left superior pulmonary vein (right picture, LAO view) in flower configuration.