The Yin and Yang of the persistent atrial fibrillation catheter ablation: Posterior wall isolation and novel pulsed field ablation technology

Abstract

Catheter ablation studies in persistent atrial fibrillation (PeAF) patients demonstrated that further ablation is required beyond the standard approach of pulmonary vein isolation (PVI). 1 However, there is no specific recommendation for the PVI plus approach including left atrial posterior wall isolation (LAPWI) in PeAF patients. There are conflicting data about the role of empirical or adjunctive LAPWI because of the lack of standardized methodology (box vs. direct or cryoballoon vs. radiofrequency). [2][3][4][5][6][7] Nevertheless, recent metaanalyses supported the additional benefit of LAPWI in PeAF patients. 3,4 In addition to currently used thermal energies (cryothermal and radiofrequency), a novel pulsed-field ablation (PFA) technology recently emerged as a nonthermal ablation modality causing electroporation-based cell death which creates intermittent, high-amplitude electric fields to achieve irreversible cellular and selective tissue destruction. 8 Although the efficacy and safety of the PFA for PVI in AF patients have been reported in various studies, [8][9][10][11][12][13][14] the data regarding the LAPWI via PFA is scarce 15-18 (Figure 1). In the current issue of theJournal of Cardiovascular Electrophysiology, Schiavone et al. 21 reported the efficacy and safety outcomes of the ATHENA (Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice) prospective and multicenter registry in which consecutive patients (n = 249, 21.7% long-standing PeAF) underwent PeAF catheter ablation using the FARAPULSE™-PFA system (Boston Scientific). The study population included nonrandomized real-world patients and the LAPWI decision was decided by the operators which created a risk of selection bias. LAPWI was achieved via debulking rather than box isolation using a flower configuration of the device. The procedures were guided by either 3-dimensional electroanatomical mapping (3D-EAM), intracardiac echocardiography (ICE), or fluoroscopy.