Conventional pulsed-field ablation versus pulsed-field ablation with non-integrated three-dimensional mapping for paroxysmal and persistent atrial fibrillation ablation

Background: There is limited evidence on efficiency, effectiveness, and safety outcomes in the context of pulsed-field ablation (PFA) of atrial fibrillation (AF) when a 3D mapping system is used. Purpose: To assess the impact of non-integrated 3D mapping systems in PFA for the treatment of AF. Methods: Consecutive patients undergoing PFA (FARAPULSE system) at 17 centers were included. Procedures were stratified according to the use of 3D mapping system (MAP vs standard; STD). Results: A total of 1804 patients were included, 484 (26.8%) with a 3D mapping system. MAP procedures had longer skin-to-skin (90 [75–120] min vs. 60 [50–70] min, p < 0.0001), cath lab utilization (120 [100–165] min vs. 70 [60–94] min, p < 0.0001), and fluoroscopy time (22 [17–28] min vs. 15 [11–21] min, p < 0.0001). The use of 3D mapping was not associated with a better long-term clinical outcome in the overall population (freedom from AF/atrial tachycardia (AT) of 82.5% in MAP procedures vs. 77.4% in STD procedures, HR = 0.737, 95% CI 0.53–1.03, p = 0.0746) as well as in PVI-only paroxysmal AF (86.5% vs. 80.3%, 0.67, 0.38–1.19, p = 0.172), in PVI plus additional lesion sets paroxysmal AF (72.7% vs. 77.8%, 1.08, 0.44–2.65, p = 0.869), or in PVI only persistent AF (76.0% vs. 68.0%, 0.86, 0.36–2.04, p = 0.727). A significantly higher arrhythmia recurrence-free rate was noticed in patients with persistent AF undergoing additional lesion set ablation (83.7% vs 70.3%, 0.45, 0.24 to 0.86, p = 0.016). Three major complications (0.2%) occurred, all in the STD group. Conclusion: The use of a non-integrated 3D mapping system for PFA of AF did not significantly affect long-term success rates in paroxysmal AF or in patients undergoing PVI-only procedures.