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Background: The role of catheter ablation in elderly patients with atrial fibrillation (AF) is unclear. Pulsed field ablation (PFA) demonstrates a favorable clinical profile, however, data on elderly patients are lacking., Aims: We aimed to assess the safety and efficacy of PFA in the elderly, using data from the EU-PORIA registry., Methods: Periprocedural complications and long-term safety and efficacy outcomes of AF ablation using the pentaspline PFA catheter (Farapulse™) were compared between patients older than 80 years old and their younger counterparts, across seven European centers., Results: Among the 1233 patients in the registry, 88 (7.1 %) were older than 80 years. Elderly patients were more often females (51.1 % vs 37.8 %, p = 0.01) with a lower median BMI (26.0, IQR:23.5-29.2 vs 26.9, IQR:24.4-30.4 kg/m 2 , p = 0.02), a higher median CHA 2 DS 2 -VASc score (4, IQR:3-5 vs 2, IQR:1-3, p < 0.001) and a higher incidence of hypertension (73.9 % vs 52.7 %, p < 0.001). In both groups, most patients had paroxysmal AF (58.0 % vs 60.3 %, p = 0.65). Ablation in the elderly was more frequently performed with minimally interrupted anticoagulation (87.5 % vs 59.7 %, p < 0.001). Despite comparable rates of overall complications (5.7 % vs 3.5 %, p = 0.29), elderly patients had a higher incidence of stroke (2.3 % vs 0.3 %, p = 0.04). At 12 months, major adverse clinical events (4.5 % vs. 2.1 %, p = 0.12) and arrhythmia-free survival (70 % vs 74 %, p = 0.69) were comparable in both groups. None of the recurrence-free elderly patients were on antiarrhythmic drugs at the end of follow-up., Conclusion: In this real-world cohort, the efficacy of PFA for AF was similar in elderly and younger patients. Despite comparable complication rates, a higher incidence of stroke was observed in the elderly., Competing Interests: Declaration of competing interest R.M.: none. V.S.: none. B.S. is a consultant for and has received honoraria as well as research funding from Abbott, Medtronic, Boston Scientific, and Biosense Webster. S.B. has received honoraria from Medtronic and Biosense Webster. K.R.J.C. is a consultant for and has received honoraria as well as research funding from Abbott, Medtronic, Boston Scientific, and Biosense Webster. T.R. has received research grants from the Goldschmidt-Jacobson Foundation, the Swiss National Science Foundation, the Swiss Heart Foundation, and the sitem insel support fund, all for work outside the submitted study. He has received speaker/consulting honoraria or travel support from Abbott/SJM, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Farapulse, Medtronic, and Pfizer-BMS, all for work outside the submitted study. He has received support for his institution's fellowship program from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific, and Medtronic for work outside the submitted study. T.K.: none. K.N. is a consultant for Biosense Webster, Boston Scientific, Field Medical, and LifeTech Scientific. N.R.: consultant for Boston Scientific. J.H.: speakers fees from Boston Scientific and Biosense Webster. M.H.R.: none. P.v.d.V.: none. Y.B. has received research grants from Medtronic and Atricure. He has received speaker/consulting honoraria from Abbott/SJM and Boston-Scientific, all for work outside the submitted study. S.J.: none. B.A.M.: none. S.B. is consultant for Medtronic, Boston Scientific, Microport, and Zoll., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Pulsed-field ablation (PFA) is a novel nonthermal ablation technology with high procedural safety and efficiency for pulmonary vein isolation (PVI). Premarket data showed high PVI durability during mandatory remapping studies. Data on lesion durability in real-world patients with clinically indicated redo procedures are scarce., Objectives: This study sought to report PVI durability rates in patients undergoing a clinically indicated redo procedure after an index PVI using PFA., Methods: Patients from 7 European centers undergoing an index PVI using PFA were included the EU-PORIA (European Real-world Outcomes With Pulsed Field Ablation in Patients With Symptomatic Atrial Fibrillation) registry. In patients with subsequent left atrial redo procedures due to arrhythmia recurrence, 3-dimensional electroanatomical maps were acquired. PVI durability was assessed on a per-vein and per-patient level, and sites of reconnections and predictors of lesion durability were identified., Results: Of 1,184 patients (62% paroxysmal atrial fibrillation) undergoing an index PVI using PFA, 272 (23%) had an arrhythmia recurrence. Of these, 144 (53%) underwent a left atrial redo procedure a median of 7 (Q1-Q3: 5-10) months after the first ablation. Three-dimensional electroanatomical maps identified 404 of 567 pulmonary veins (71%) with durable isolation. In 54 patients (38%), all pulmonary veins were durably isolated. Prior operator experience with cryoballoon ablation was associated with a higher PVI durability compared to operators with only point-by-point radiofrequency experience (76% vs 60%; P < 0.001). Neither the operators' cumulative experience in atrial fibrillation ablation (≤5 vs >5 years) nor the size of the PFA device used (31 mm vs 35 mm) had an impact on subsequent lesion durability (both P > 0.50)., Conclusions: In 144 patients with arrhythmia recurrence after PFA PVI, durable isolation was observed in 71% of the pulmonary veins during the redo procedure, and 38% of all patients showed durable isolation of all veins., Competing Interests: Funding Support and Author Disclosures The EU-PORIA registry was supported by a research grant from Boston Scientific. Dr Bordignon has received honoraria from Medtronic and Biosense Webster. Dr Neven has served as a consultant for Biosense Webster, Boston Scientific, Field Medical, and LifeTech Scientific. Dr Blaauw has received research grants from Medtronic and Atricure; has received speaker/consulting fees from Abbott/St Jude Medical and Boston-Scientific, all for work outside the submitted study. Dr Hansen has received speaker fees from Boston Scientific and Biosense Webster. Dr Füting has received an educational grant from Boston Scientific. Dr Roten has received research grants from Medtronic and speaker/consulting fees from Abbott and Medtronic. Dr Reinsch has served as a consultant for Boston Scientific. Dr Boveda has served as a consultant for Medtronic, Boston Scientific, Microport, and Zoll. Drs Albrecht and Schneider are salaried employees of Boston Scientific. Dr Chun has served as a consultant for and has received honoraria as well as research funding from Abbott, Medtronic, Boston Scientific, and Biosense Webster. Dr Schmidt has served as a consultant for and has received honoraria as well as research funding from Abbott, Medtronic, Boston Scientific, and Biosense Webster. Dr Reichlin has received research grants from the Goldschmidt-Jacobson Foundation, the Swiss National Science Foundation, the Swiss Heart Foundation and the sitem insel support fund, all for work outside the submitted study; has received speaker/consulting fees or travel support from Abbott/St Jude Medical, Biosense Webster, Biotronik, Boston Scientific, and Medtronic; and has received support for his institution’s fellowship program from Abbott/St Jude Medical, Biosense Webster, Biotronik, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)