Learning curve and procedural efficiency of zero-fluoroscopy pulsed-field ablation for atrial fibrillation.

Background: Pulsed-field ablation (PFA) has demonstrated safety and noninferiority compared with radiofrequency ablation (RFA) for atrial fibrillation. However, real-world data comparing RFA and PFA using a zero-fluoroscopy workflow, particularly regarding acute procedural efficiency and outcomes, remain limited.

Objective: This study aimed to compare procedural characteristics of zero-fluoroscopy RFA and PFA pulmonary vein isolation (PVI) at a high-volume academic institution.

Methods: We analyzed 827 consecutive zero-fluoroscopy first-time ablations performed between January 2022 and March 2025. Only patients with PVI or PVI with posterior wall isolation (PWI) lesion sets were included. Procedure time was defined as venous access to sheath removal time. Mixed-effects regression models were used for statistical analysis.

Results: The mean age was 65 ± 10 years, 68% of patients were male, and 54% had paroxysmal atrial fibrillation. Zero-fluoroscopy RFA and PFA procedures were 25 and 14 minutes shorter, respectively, than fluoroscopy-guided procedures (P < .001). Zero-fluoroscopy procedure time was significantly reduced with PFA compared with RFA (-25 minutes), particularly during PVI + PWI (PVI -16 minutes; PVI + PWI -28 minutes) (P < .001). The learning curve for zero-fluoroscopy PFA did not vary by physician or years of experience and plateaued after 114 total PFA cases. Based on the mixed-effects model analysis, each additional PFA case performed reduced procedure time by 0.5 minutes (P < .001). Severe complications were rare (0.48%), with no significant difference between energy types.

Conclusion: Zero-fluoroscopy PFA is safe and effective, with comparable acute procedural outcomes and safety profile with zero-fluoroscopy RFA. The zero-fluoroscopy PFA learning curve is independent of career stage or physician.