Pulsed-Field Ablation Versus Radiofrequency Ablation Combined Ethanol infusion via the vein of Marshall for Mitral Isthmus Line ablation in Persistent Atrial Fibrillation

doi:10.1101/2025.11.20.25340707

Pulsed-Field Ablation Versus Radiofrequency Ablation Combined Ethanol infusion via the vein of Marshall for Mitral Isthmus Line ablation in Persistent Atrial Fibrillation

2025 · doi:10.1101/2025.11.20.25340707

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Pulsed-field ablation achieved higher acute mitral isthmus block and shorter procedure times than RF ablation with ethanol, but showed greater early reconnection.

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⚙ AI-generated deep summary by claude@2026-07, 2026-07-15 · read from full text ⓘ

This prospective, single-center observational cohort study compared pulsed-field ablation (PFA) versus ethanol infusion via the vein of Marshall combined with radiofrequency (EIVOM+RF) for creating a mitral isthmus line in consecutive patients undergoing first-time catheter ablation for persistent atrial fibrillation. Using standardized mapping and pacing criteria, it found that while immediate bidirectional mitral isthmus block was similar between groups, PFA achieved a higher first-pass block rate (98.2% vs 73.2%) and substantially shorter total mitral isthmus ablation time (median 6.1 vs 24 minutes), but had lower sustained block after a 20-minute waiting period (73.2% vs 89.8%). Residual conduction gaps also differed by modality, clustering mid-isthmus near the great cardiac vein for PFA and near the pulmonary vein/ridge region for EIVOM+RF, with similarly low major complications. The paper does not explicitly state limitations beyond its design as a prospective observational cohort. The paper does not explicitly discuss endometriosis or adenomyosis; it was included in the corpus via a keyword match in the upstream search index.

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Abstract

Background Durable mitral isthmus (MI) bidirectional block is an important substrate endpoint for persistent atrial fibrillation (PeAF) ablation. Radiofrequency (RF) ablation with adjunctive ethanol infusion via the vein of Marshall (EIVOM) improves epicardial lesion formation and MI block durability; pulsed-field ablation (PFA) is a non-thermal alternative that produces rapid myocardial ablation but its acute lesion durability and gap distribution at the MI are not well defined. We compared acute procedural efficacy, lesion durability after a standardized waiting period, ablation time, gap distribution, and safety between PFA and EIVOM+RF for MI line ablation in PeAF. Methods In this prospective, single-center observational cohort, consecutive patients with symptomatic PeAF undergoing first-time catheter ablation with a planned MI line were enrolled. Analyses included 164 patients (PFA, n=56; EIVOM+RF, n=108). Procedures used standardized mapping and pacing criteria to define bidirectional MI block. Study endpoints include acute bidirectional MI block at the end of ablation, immediate block after MI initial ablation, MI reconnection rate after 20 minutes observation period and total MI ablation time. Residual gap locations and peri-procedural complications were also recorded. Between-group comparisons used appropriate univariate tests. Results Immediate bidirectional MI block was achieved in 100% of PFA cases versus 97.2% of EIVOM+RF cases (P=0.552). First-pass MI block was significantly higher with PFA (98.2% vs 73.2%; P<0.001). After a 20-minute waiting period, sustained bidirectional block remained in 73.2% of PFA patients versus 89.8% of EIVOM+RF patients (P=0.012). Acute bidirectional MI block at procedure end was 96.4% in PFA group versus 90.7% in EIVOM+RF group (P=0.224). Mean total MI ablation time was markedly shorter with PFA (median 6.1 minutes [IQR 3–8] vs 24 minutes [IQR 16–33]; P<0.001). Residual conduction gaps clustered at the mid-isthmus adjacent to the great cardiac vein in the PFA group (8/13 gaps, 61.5%), whereas gaps in the EIVOM+RF group clustered near the pulmonary vein/ridge region (6/11 gaps, 63.6%). Major complication rates were low and similar between groups (one small self-resolving pericardial effusion in EIVOM+RF; one transient coronary spasm in PFA). Conclusions In this prospective cohort of PeAF patients, focal PFA achieved very high acute and first-pass MI block rates and substantially reduced MI ablation time compared with EIVOM+RF but demonstrated greater early reconnection after a 20-minute observation period. The two strategies produced different patterns of residual conduction gaps (PFA: mid-isthmus/GCV; EIVOM+RF: PV-ridge), suggesting modality-specific lesion characteristics. These findings support PFA as an efficient approach to MI line creation but indicate that prolonged observation may be required to secure durable MI block with PFA. Further studies assessing longer-term rhythm outcomes and optimized PFA protocols (including potential hybrid approaches) are warranted.

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Abstract

Methods

In this prospective, single-center observational cohort, consecutive patients with symptomatic PeAF undergoing first-time catheter ablation with a planned MI line were enrolled. Analyses included 164 patients (PFA, n=56; EIVOM+RF, n=108). Procedures used standardized mapping and pacing criteria to define bidirectional MI block. Study endpoints include acute bidirectional MI block at the end of ablation, immediate block after MI initial ablation, MI reconnection rate after 20 minutes observation period and total MI ablation time. Residual gap locations and peri-procedural complications were also recorded. Between-group comparisons used appropriate univariate tests.

Results

Immediate bidirectional MI block was achieved in 100% of PFA cases versus 97.2% of EIVOM+RF cases (P=0.552). First-pass MI block was significantly higher with PFA (98.2% vs 73.2%; P<0.001). After a 20-minute waiting period, sustained bidirectional block remained in 73.2% of PFA patients versus 89.8% of EIVOM+RF patients (P=0.012). Acute bidirectional MI block at procedure end was 96.4% in PFA group versus 90.7% in EIVOM+RF group (P=0.224). Mean total MI ablation time was markedly shorter with PFA (median 6.1 minutes [IQR 3–8] vs 24 minutes [IQR 16–33]; P<0.001). Residual conduction gaps clustered at the mid-isthmus adjacent to the great cardiac vein in the PFA group (8/13 gaps, 61.5%), whereas gaps in the EIVOM+RF group clustered near the pulmonary vein/ridge region (6/11 gaps, 63.6%). Major complication rates were low and similar between groups (one small self-resolving pericardial effusion in EIVOM+RF; one transient coronary spasm in PFA).

Conclusions

In this prospective cohort of PeAF patients, focal PFA achieved very high acute and first-pass MI block rates and substantially reduced MI ablation time compared with EIVOM+RF but demonstrated greater early reconnection after a 20-minute observation period. The two strategies produced different patterns of residual conduction gaps (PFA: mid-isthmus/GCV; EIVOM+RF: PV-ridge), suggesting modality-specific lesion characteristics. These findings support PFA as an efficient approach to MI line creation but indicate that prolonged observation may be required to secure durable MI block with PFA. Further studies assessing longer-term rhythm outcomes and optimized PFA protocols (including potential hybrid approaches) are warranted. Competing Interest Statement The authors have declared no competing interest. Clinical Trial This is a prospective observational study. Funding Statement None Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This research has undergone review and approval by the Ethics Committee of Beijing Anzhen Hospital affiliated Capital Medical University. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability The data that support the findings of this study are available from the corresponding author upon reasonable request.

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