Ensuring catheter-tissue contact with intracardiac echocardiography during pulsed-field ablation improves procedure outcome in patients with atrial fibrillation

Background: Catheter-tissue contact is critical in creating durable lesions during pulsed-field ablation (PFA) of atrial fibrillation (AF). Objective: This study aimed to compare the reconnection rate of previously ablated targets using PFA with vs without intracardiac echocardiography (ICE) guidance for confirmation of tissue contact. Methods: This multicenter prospective study included consecutive patients with paroxysmal and persistent AF undergoing their first procedure using the PFA system. Patients were classified as the ICE group if ICE was used for the assessment of catheter-tissue contact (n = 310) or the fluoro group if fluoroscopy-guided ablation was used (n = 286). All patients received isolation of pulmonary veins; left atrial posterior wall isolation was performed in most patients at the index procedure. Further ablations were performed only in the presence of spontaneous triggers or documentation that those triggers were responsible for arrhythmia either spontaneously or after isoproterenol challenge. Results: Baseline characteristics were comparable between the groups. At the end of the follow-up, arrhythmia recurrence was noted in 39 (12.6%) and 64 patients (22.3%) in the ICE and fluoro groups, respectively (P = .002). All 39 patients in the ICE group and 54 patients (84%) in the fluoro group received repeat ablation. At the redo procedure, reconnection of previously ablated structures was detected in 4 of 39 (10.3%) and 32 of 54 patients (59.2%) in the ICE and fluoro groups, respectively (P < .001). “Fluoroscopy-guided” ablation was found to be an independent predictor of reconnection (odds ratio 8.548; 95% confidence interval 3.224–22.667; P < .001) and recurrence (odds ratio 1.221; 95% confidence interval 1.001–1.971; P = .021). Conclusion: ICE-guided PFA with confirmed catheter-tissue contact was associated with a better success rate and a significantly lower reconnection rate in patients with AF.