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Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). PFA can be performed "cryo-style" using fluoroscopy only, or additional pre- and post-ablation high-density 3D bipolar voltage maps can be performed to assess lesion formation and acute pulmonary vein isolation. We compared 6-month outcome after PFA using fluoroscopy only (X-ray) vs. PFA guided by 3D mapping (3D). Methods In PAF patients, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps (Carto 3D) were performed. Procedural parameters, acute success, in-hospital safety and arrhythmia recurrence were assessed over 6-month follow-up. Efficacy was evaluated by freedom from a ≥ 30-sec. recurrence of AF/atrial flutter (AFL)/atrial tachycardia (AT). Follow-up included 7-day Holter ECGs and/or telephonic interviews at days 90 and 180 after ablation. Results This study included a total of 101 patients (mean age: 65±10 years; 42% female) in whom 6-month follow-up data were available. There were no selection criteria for the use of 3D mapping. Pre- and post-ablation high-density maps were performed in 34/101 (34%) of patients. Mean CHA2DS2-VASc-score was 2,1±1,6. Median duration since first AF diagnosis was 21 [3-60] months. Skin-to skin procedure time was 56±20 in the X-ray group vs. 118±22 min in the 3D group, respectively (p Conclusions PVI using PFA with or without 3D mapping system resulted in a similar 6-month atrial arrhythmia recurrence rate and safety profile. Procedure and fluoroscopy times were significantly shorter in the fluoroscopy only group.

Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). Only a few small clinical studies have been published on the mid- and long-term outcome. Here, we present the one-year clinical outcomes of PFA in PAF. Methods In PAF patients, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps using a pentaspline diagnostic cathter were performed. Procedural parameters, acute success, in-hospital safety and arrhythmia recurrence were assessed during one-year follow-up. Efficacy was evaluated by freedom from a ≥ 30-sec. recurrence of AF/atrial flutter (AFL)/atrial tachycardia (AT). Follow-up included 7-day Holter ECGs and/or telephonic interviews at days 90, 180 and 360 days after ablation. Results This study included a total of 108 patients (mean age 65±10 years; 44% female). Mean CHA2DS2-VASc-score was 2,3±1,7. Mean duration since first AF diagnosis was 45±63 months. Pre- and post-ablation high-density maps were performed in 36/108 (33%) of patients. Skin-to skin procedure time was 78±36 min. Fluoroscopy time and dose area product were 19±8 min and 5,56±4,64 Gy.cm2, respectively. Left atrial dwell time of the PFA catheter was 27±11 min. Acute PVI rate was 100% of PVs using PFA only. Primary adverse events occurred in 3,7% of patients (1 groin hematoma, 2 pericardial tamponades, 1 acute stroke with lethal outcome). No patients were lost during FU. During a mean FU of 346±64 days, 88 of 107 patients (82%) remained free of any symptomatic or documented AF/AFL/AT episode after a single procedure. After the 90-day blanking period, in 19 (18%) patients at least one episode of AF/AFL/AT was documented. In 14/107 (13%) patients, after 216±102 days a re-do procedure was performed. In 7/107 (7%) patients, PV reconduction was seen. In 5/107 (5%) patients, during re-do procedure clinical or induced typical or atypical flutter was treated in presence of durable PV isolation. In the remaining 2/107 (2%) patients, only clinical right atrial typical flutter was treated and no left atrial mapping was performed. Conclusions PVI using PFA in patients with a relatively long history of PAF results in a low one-year atrial arrhythmia recurrence rate. The success rate may be reduced due to the long duration since first AF diagnosis and the initial experience with PFA by the operators. PV reconduction rate during re-do procedure in a limited number of patients was 7%. There was a reasonable safety profile and it improved significantly over the course of time, indicating that the learning curve could have negatively influenced the incidence of complications. Figure: Kaplan-Meier analysis of freedom from atrial arrhythmias, including any AF/AFL/AT episode exceeding 30 sec. Not including the 3-month blanking period.

Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (AF). It is also used as off-label therapy for persistent AF. Only a few small clinical studies have been published on the mid- and long-term outcome. We present data on methods, efficacy and safety on routine clinical use of pulsed field ablation for pulmonary vein isolation in patients with atrial fibrillation. Methods In patients with AF, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps using a pentaspline diagnostic catheter were performed. Procedural parameters, acute success and in-hospital safety were assessed. Results A total of 5 operators treated 304 patients (mean age 67 years (range 32-85), female 42%, mean BMI 28 kg/m2 (range 20-42), mean CHA2DS2-VaSc score of 2 (range 0-7), first-time ablation 100%, paroxysmal/persistent/longstanding persistent AF 47/17/36%, respectively. Mean duration since first AF diagnosis was 79 months (range 0-332). Most procedures were performed under deep conscious sedation using propofol and midazolam, without intubation (99%). Pre- and post-ablation high-density maps were performed in 27% of cases. Mean procedure time was 75 min. (range 23–245). Mean left atrial dwell time of the PFA catheter was 25 min. (range 8-98). Fluoroscopy time and dose area product were 18 min. (range 6-50) and 5,74 Gy.cm2 (range 0,40-36,50), respectively. Pulmonary vein isolation (PVI) was successful in 100%. There were no phrenic nerve palsies or esophageal complications. Major complications (2,6%) were pericardial tamponade (2,0%) and stroke (0,7%); one of these strokes was lethal (0,3%). Minor complications (1,0%) were vascular access related (0,7%) and transient ischemic attack (TIA) (0,3%). Conclusions In a large, single center cohort of unselected patients, initial experience with de novo PFA for PVI in patients with AF seems to be fast and effective. There were no PFA-specific complications, but the frequency of catheter complications (tamponade, stroke) in this relatively old patient population with a relatively long history of AF demonstrates that there is still room for improvement. The number of complications improved significantly over the course of time, indicating that the learning curve could have negatively influenced the incidence of complications.

Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). Only very limited data on learning curves after implementing this new technique in clinical practice exist. We present data from our experience with learning curves using pulsed field ablation for atrial fibrillation. Methods In patients with paroxysmal or persistent AF, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. No 3D mapping system was used. Total procedure time, left atrial (LA) dwell time, time from first to last ablation and fluoroscopy time were analysed over the course of time. First and last chronological tertiles of each parameter were compared for statistical significance. Results This study included a total of 147 patients (mean age: 66±10 years; 41% female). Mean CHA2DS2-VASc-score was 2,4±1,5. The procedures were performed by 4 operators (3 certified EP specialists and 1 EP fellow) in random teams of 2 operators. Median skin-to skin procedure time was 47 [40;61] min. There was a statistically significant decrease between the first and last tertiles: 53 [44;68] vs. 46 [41;54] min (p Conclusions The introduction of a novel pulsed field ablation system for pulmonary vein isolation used by 4 operators leads to a significant decrease in total procedure time, LA dwell time and fluoroscopy time over the course of time, demonstrating streamlining of the ablation procedure as a whole. Time from first to last ablation remains constant, this is probably due to the standardized protocol of the ablation itself.

Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). A few small clinical studies and registries have reported an initial clinical success rate of approx. 80% after 1 year. Here, we present the results from re-do ablation after PVI using PFA for AF. Methods In symptomatic AF patients, re-do ablation in conscious sedation using a contact force sensing catheter and 45W RF energy was performed. In all patients, pre- and post-ablation high-density bipolar voltage 3D maps using a pentaspline diagnostic catheter were performed. Procedural parameters and acute success were assessed. Results Eighteen patients (age 67 years; 17% female; 56% PAF) from a total of 304 patients (age 67 years; 42% female; 47% PAF) (6%) treated with PFA as initial AF therapy underwent a re-do ablation 212 days after the index procedure. Mean CHA2DS2-VASc-score was 1,7 in the re-do group vs. 2,5 in the index procedure group. Mean duration since first AF diagnosis and BMI were not significantly different. In 12/18 (67%) patients, reconnection of at least 1 PV was found (LSPV 2x; LIPV 4x; RSPV 2x; RIPV 2x, left carina 4x; right carina 2x). All reconnected PVs were successfully reisolated. In 11/18 (61%) of patients, an atrial flutter (AFL) or tachycardia (AT) was identified (roof 5x; mitral isthmus 5x; anterior/septal 3x; cavotricuspid isthmus 5x). In 5/12 (42%) of patient with reconnection of at least 1 PV, AT/AFL occurred. In contrast, in all 6 patients (100%) with persistently isolated PVs AT/AFL occurred. All tachycardias were successfully ablated. Conclusions Re-do ablation rate after PFA for AF was relatively low (6%), involving mostly male patients. PV reconnection rate was 67%, site of PV reconnection was predominantly left-sided. In 61%, predominantly left-sided AT/AFL occurred. Notably, in all patients with persistently isolated PVs AT/AFL was observed.

Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). It is also used as off-label therapy for persistent AF. PFA can be performed "cryo-style" using fluoroscopy only, or additional pre- and post-ablation high-density 3D bipolar voltage maps can be performed to assess lesion formation and acute pulmonary vein isolation. We compared acute outcome after PFA using fluoroscopy only (X-ray) vs. PFA guided by 3D mapping (3D). Methods In patients with AF, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps (Carto 3D) were performed. Procedural parameters, acute success and in-hospital safety were assessed. Results A total of 4 operators treated 218 patients (mean age 66 years (range 35–86), female 43%, mean BMI 28 kg/m2 (range 20-42), mean CHA2DS2-VaSc score of 2,5 (range 0-7), first-time ablation 93%, paroxysmal AF/persistent AF/re-do 72/21/7%). Mean duration since first AF diagnosis was 42 months (range 1-336). Most procedures were performed under deep conscious sedation without intubation (99%). There were no selection criteria for the use of 3D mapping. Pre- and post-ablation high-density maps were performed in 28% of cases. Skin-to skin procedure time was 54±22 in the X-ray group vs. 123±35 min in the 3D group, respectively (p Conclusions In a large, single center cohort of unselected patients, PVI using PFA with or without 3D mapping system resulted in a similar acute outcome and safety profile. Procedure and fluoroscopy times were significantly shorter in the fluoroscopy only group. There were no PFA-specific complications, but the frequency of catheter complications in this relatively old patient population demonstrates that there is still room for improvement.