Predictors of atrial fibrillation freedom postablation with the pentaspline pulsed field ablation catheter: Subanalysis of the ADVENT Study.

Abstract

Background: Pulsed field ablation (PFA) has proven to be at least noninferior to thermal ablation for paroxysmal atrial fibrillation (AF). Predictors of AF freedom for PFA have not yet been described.

Objective: The purpose of this study was to identify clinical and procedural predictors of treatment success in paroxysmal AF patients treated with the pentaspline PFA catheter.

Methods: ADVENT (Randomized Controlled Trial for Pulsed Field Ablation versus Standard of Care Ablation for Paroxysmal Atrial Fibrillation) was a prospective randomized trial comparing PFA to thermal ablation with centers designated to randomize patients to either radiofrequency or cryoballoon ablation. Hazard ratios were estimated to evaluate clinical and procedural characteristics associated with ablation success. Subgroup analyses were performed by ablation modality and operator/center experience.

Results: Of the 607 randomized patients (age 62.4 years, 34.6% female), treatment failure was documented in 26.7% of PFA and 28.7% of thermal ablation patients. The most common failure was arrhythmia recurrence (73.8% vs 76.5%) with no difference in subtype (non-AF arrhythmia: 12.1% PFA vs 14.6% thermal). Patients who previously failed Class I/III antiarrhythmic drugs (AADs) were more likely to benefit from PFA (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.44-0.96). Shorter left atrial dwell time was associated with higher success (HR 0.48, 95% CI 0.30-0.76), and a trend toward better outcomes was noted for patients enrolled during the second half of the trial (75.5% vs 69.9%, P = .17). PFA patients had similar success across radiofrequency and cryoballoon centers.

Conclusion: PFA with the pentaspline catheter is not associated with a higher incidence of postablation atypical flutters/tachycardias. Patients with previous Class I/III AAD failure are more likely to benefit from PFA and greater operator experience, irrespective of previous thermal modality, may be associated with better outcomes.