Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Dec 28;26(1):euae006.
doi: 10.1093/europace/euae006.

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures

Thomas Kueffer  1   2 , Hildegard Tanner  1 , Antonio Madaffari  1 , Jens Seiler  1 , Andreas Haeberlin  1   2 , Jens Maurhofer  1 , Fabian Noti  1 , Claudia Herrera  1 , Gregor Thalmann  1 , Nikola A Kozhuharov  1 , Tobias Reichlin  1 , Laurent Roten  1
Affiliations

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures

Thomas Kueffer et al. Europace. .

Abstract

Aims: The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce.

Methods and results: Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 [IQR 61-75] years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT.

Conclusion: Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.

Keywords: Atrial fibrillation; Posterior wall ablation; Pulmonary vein isolation; Pulsed-field ablation; Reconnection.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest: A.H.: research grants from the Swiss National Science Foundation, Innosuisse, the Swiss Heart Foundation, the University of Bern, the University Hospital Bern, the Velux Foundation, the Hasler Foundation, the Swiss Heart Rhythm Foundation, and the Novartis Research Foundation. He is co-founder and CEO of Act-Inno, a cardiovascular device testing company. He has received travel fees/educational grants from Medtronic, Philips/Spectranetics, and Cairdac without impact on his personal remuneration. L.R.: speaker honoraria from Abbott/SJM, consulting honoraria from Medtronic, research grant from the sitem insel support fund and research grant to the institution from Medtronic. T.R.: research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the sitem insel support fund, Biotronik, Boston Scientific, and Medtronic, all for work outside the submitted study. Speaker/consulting honoraria or travel support from Abbott/SJM, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Medtronic, and Pfizer-BMS, all for work outside the submitted study. Support for his institution’s fellowship programme from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific, and Medtronic for work outside the submitted study. F.N.: Medtronic, Abbott: travel fees, speaker fees, educational grant; Boston Scientific, Philips Spectranetics: travel fees, educational grant; Biotronik: institutional grant all for work outside the submitted study. N.A.K.: research grants from the Swiss National Science Foundation (grant nr. P400PM-194477 and grant nr. P5R5PM_210856), Gottfried und Julia Bangerter-Rhyner-Stiftung, Freiwillige Akademische Gesellschaft, L. & Th. La Roche Stiftung, and the European Society of Cardiology. J.S.: the spouse of Dr Seiler is an employee of Boston Scientific and stock owner of Boston Scientific and Abbott. T.K.: research grant from the Swiss Heart Foundation. All other authors report no conflicts of interest related to this paper.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Workflow for posterior wall ablation using pulsed-field ablation. After pulmonary vein isolation, four additional anchor lesions per vein in flower configuration and with posterior torque on the FARADRIVE sheath were placed to extend the lesion further into the posterior wall (A). Successive ablation of the posterior wall was achieved by targeting the entire space between the left and right pulmonary veins with pairwise, overlapping applications and without rotation of the device. PW, posterior wall.
Figure 2
Figure 2
Indications for posterior wall ablation. Indication to perform posterior wall ablation was either: A) presence of posterior wall scar, identified by 3D-EAM; B) left atrial tachycardia; C) no posterior wall scar (asterisk): PWA was performed either due to recurrence despite durable PVI or as a first-line treatment strategy based on the patient’s medical history; and D) anatomical reasons (dagger): PWA was performed either due to a narrow surviving channel after PVI or due to an anomalous roof vein. 3D-EAM, 3D-electroanatomical mapping; LA, left atrial; PWA, posterior wall ablation.
Figure 3
Figure 3
Procedure overview. Overview and procedural details for posterior wall ablation using PFA in 215 patients. A) Number of cases for each indication. B) Extra-pulmonary vein targets additional to PWA for each indication. Substrate ablation denotes the elimination of additional atrial tachycardia originating from a scar area that is not amenable to linear ablation. C and D) Differences in procedure duration and X-ray time. CTI, cavotricuspid isthmus; LA, left atrium; MIL, mitral isthmus line; PFA, pulsed-field ablation; PWA, posterior wall ablation; SVC, superior vena cava.
Figure 4
Figure 4
Kaplan-Meier analysis. Outcome after posterior wall ablation using pulsed-field ablation in 215 patients. No difference in arrhythmia-free outcome was found for persistent AF vs. paroxysmal AF patients, for patients with vs. without posterior wall scar, and for performing PWA during the first vs. during a redo procedure. AF, atrial fibrillation; PWA, posterior wall ablation.
See this image and copyright information in PMC

References

    1. Metzner A, Kuck KH, Chun JKR. What we have learned: is pulmonary vein isolation still the cornerstone of atrial fibrillation ablation? Europace 2022;24:ii8–ii13. - PubMed
    1. Sorensen SK, Johannessen A, Worck R, Hansen ML, Hansen J. Radiofrequency versus cryoballoon catheter ablation for paroxysmal atrial fibrillation: durability of pulmonary vein isolation and effect on atrial fibrillation burden: the RACE-AF randomized controlled trial. Circ Arrhythm Electrophysiol 2021;14:e009573. - PMC - PubMed
    1. Jongbloed MR, Schalij MJ, Poelmann RE, Blom NA, Fekkes ML, Wang Z et al. Embryonic conduction tissue: a spatial correlation with adult arrhythmogenic areas. J Cardiovasc Electrophysiol 2004;15:349–55. - PubMed
    1. de Groot N, van der Does L, Yaksh A, Lanters E, Teuwen C, Knops P et al. Direct proof of endo-epicardial asynchrony of the atrial wall during atrial fibrillation in humans. Circ Arrhythm Electrophysiol 2016;9:e003648. - PubMed
    1. Pambrun T, Duchateau J, Delgove A, Denis A, Constantin M, Ramirez FD et al. Epicardial course of the septopulmonary bundle: anatomical considerations and clinical implications for roof line completion. Heart Rhythm 2021;18:349–57. - PubMed