Pulsed Field Ablation with a Pentaspline Catheter and Concomitant Left Atrial Appendage Closure for Long-Standing Persistent Atrial Fibrillation: Comparison with a Radiofrequency Cohort

Background: Pulsed field ablation (PFA) is increasingly being adopted for atrial fibrillation (AF) ablation, but outcome data when it is combined with left atrial appendage occlusion (LAAO) remain limited. Objective: We evaluated outcomes of extensive PFA combined with LAAO, compared with radiofrequency ablation plus LAAO in patients with long-standing persistent AF. Methods: In this observational, multicenter, propensity-matched study, 90 consecutive patients with drug-refractory, long-standing persistent AF underwent combined ablation (pulmonary veins, posterior wall, and LAA electrical isolation) plus LAAO (45 PFA, 45 RF). Matching was 1:1 based on age, CHA2DS2-VASc score, HAS-BLED score, and LAAO device. Follow-up was censored at 12 months. Results: Baseline characteristics were balanced after matching. Procedural time was shorter with PFA than RF (86.0±6.8 vs. 114.5±11.5 minutes, p=0.042). Acute LAAO success was 100% in both groups, with similar complication rates (one pericardial effusion each). Overall peridevice leak (PDL) incidence was lower with PFA (8.9% vs. 24.4%, p=0.048), although clinically relevant leaks >3 mm were infrequent and comparable (0% vs. 4.4%, p=0.494). At 12 months, arrhythmic recurrences were numerically lower with PFA (22.2% vs. 40.0%, p=0.069; log-rank p=0.093). No strokes or major bleeding occurred in the PFA cohort, while 1 non-cardioembolic stroke and 2 major bleeding events occurred in the RF group. In Cox regression, only AF duration >18 months predicted recurrence (HR=3.27, 95%CI 1.15-9.32; p=0.027). Conclusion: Extensive PFA, including LAA electrical isolation, combined with LAAO was feasible and safe, resulting in shorter procedures, fewer overall PDLs compared with RF but similar rate of PDL>3 mm.