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Aims: Ablation modalities differ in their mechanisms of action, tissue specificity, and collateral effects-particularly on the cardiac autonomic nervous system. This study aimed to compare the autonomic effects of pulsed field ablation (PFA) vs. thermal ablation (TA) in patients with atrial fibrillation (AF) through a pooled analysis.

Methods and results: A systematic search of PubMed and Embase was conducted through 5 April 2025, to identify comparative studies. The primary outcome was increase in heart rate (IHR) after ablation, and the secondary outcome was increase in serum S100B (IS100B), a marker of neural injury. Eight studies involving 1007 AF patients were included (mean age: 63.39 ± 10.75 years; 36.3% female; maximum follow-up: 12 months). Baseline characteristics, including the use of antiarrhythmic drugs, were similar between the PFA and TA groups. Pooled analysis showed that PFA was associated with a significantly lower IHR compared to TA (PFA: 4.41 ± 8.86 bpm vs. TA: 10.81 ± 10.46 bpm; P < 0.00001). This difference persisted at midterm (3-6 months) and long-term (12 months) follow-up and remained consistent across age, sex, and different TA modalities (cryoballoon vs. radiofrequency). Correspondingly, the IS100B was significantly less pronounced after PFA (PFA: 33.27 ± 9.46 pg/mL vs. TA: 97.53 ± 31.88 pg/mL; P < 0.00001).

Conclusion: PFA-based pulmonary vein isolation in patients with AF results in a smaller post-procedural IHR and less S100B release, suggesting reduced neural damage and less disruption of the autonomic nervous system compared to TA. These effects are sustained through mid- to long-term follow-up and may have potential implications for patient selection and individualized ablation strategies.

Aims: There is still conflicting evidence if women with persistent atrial fibrillation (AF) profit from a pulmonary vein isolation (PVI) plus strategy. We evaluated the efficacy of a spatio-temporal dispersion-targeted ablation strategy in women from the TAILORED-AF trial.

Methods and results: In TAILORED-AF, 370 patients were randomised to either a personalised, artificial intelligence (AI)-guided tailored ablation or to PVI-only. AF substrate mapping data and 12-month ablation outcomes were compared between women and men. Overall, 21% patients were female (70.4 ± 6.9 vs. 64.5 ± 8.5 years for men, P < 0.001). While spatio-temporal dispersion extent was similar between groups, left atrial low-voltage surface area (<0.2 mV) was significantly larger in women (P < 0.01). In women, the single-procedure freedom from AF (76% vs. 50%, log-rank P < 0.001) and any atrial arrhythmia (56% vs. 38%, log-rank P < 0.05) were significantly superior to PVI alone with a tailored procedure. In the PVI-only group, the single-procedure freedom from AF (50% vs. 70%, log-rank P < 0.001) and any atrial arrhythmia (38% vs. 61%, log-rank P < 0.001) were significantly lower in women. After a tailored ablation, no significant differences were observed between women and men regarding freedom from AF (76% vs. 91%, log-rank P = 0.07) or any atrial arrhythmia (56% vs. 62%, log-rank P = 0.69) free survival.

Conclusion: Compared to men, PVI-only in women with persistent AF leads to a significantly lower freedom from atrial arrhythmia. A personalised spatio-temporal dispersion-targeted ablation strategy led to a higher rate of freedom from any atrial arrhythmia than standard PVI after a single procedure in women and comparable outcomes between women and men.

Registration identification: clinicaltrials.gov NCT04702451.

Aims: Same-day discharge (SDD) following catheter ablation for atrial fibrillation (AF) yields a promising approach to enhance patient satisfaction and reduce healthcare costs. While prior data support the safety of SDD after radiofrequency ablation, evidence following pulsed field ablation (PFA) remains limited. This sub-analysis of the admIRE trial (NCT05293639) evaluates the safety of SDD compared with overnight stays (ONS) after PFA using a variable-loop circular catheter (VLCC).

Methods and results: Baseline and procedural characteristics, safety, and effectiveness were compared between SDD and ONS groups. Primary effectiveness was defined as freedom from composite failure using Kaplan-Meier estimates. Serious adverse events (SAEs) occurring ≤7 days and ≥1 day post-index procedure were assessed. Amongst 277 patients in the admIRE trial, 119 (43.0%) completed SDD, and 158 (57.0%) stayed overnight. The SDD group included fewer patients aged ≥65 years (41.2% vs. 52.5%), shorter fluoroscopy times (4.0 vs. 8.9 min), higher first-pass isolation rates (97.5% vs. 82.9%), and fewer procedural AEs (1.7% vs. 3.8%). More procedures in the SDD group occurred in the morning (63.0% vs. 39.2%). Freedom from primary effectiveness failure was similar (SDD, 75.4% [95% CI 67.4-83.3%] vs. ONS, 74.0% [95% CI 66.4-81.5%]). No significant difference in SAE risk was observed overall [HR, 1.07 (95% CI 0.47-2.44)] or ≤7 days post-procedure [HR, 0.78 (95% CI 0.17-3.49)]. Post-procedural serious cardiac/vascular AE rates were also comparable (SDD, 2.5% vs. ONS, 1.3%).

Conclusion: SDD is feasible in a paroxysmal AF population undergoing PFA with the VLCC, demonstrating comparable safety and effectiveness outcomes with overnight hospitalization.

Aims: Pulsed Field ablation (PFA) is a non-thermal ablation modality with functional myocardial sparing. Recent evidence suggests that clinically used PFA systems may produce non-negligible thermal effects, particularly at the tissue-catheter interface, potentially increasing the risk of thrombo-embolic complications. This study sought to characterize the temperature dynamics of two PFA pulse waveforms, delivered using a variable-loop circular catheter, under different irrigation conditions.

Methods and results: In total, 132 ablations were performed on 31 bovine myocardial tissue specimens, using Sequence_1 and Sequence_2 at two different irrigation rates-4 and 30 mL/min. Maximum temperatures and their rise from baseline were measured at the tissue surface, and at 3 and 7 mm depths, across different ablation conditions. Sequence_1 at 4 mL/min produced the highest surface temperature (56.4°C [54.9-58.4]) and temperature rise (ΔT: 19.4°C [17.9-21.4]). Sequence_2 at 30 mL/min showed the most favourable thermal profile, with significantly lower surface temperatures (40.8°C [37.9-43.0], ΔT: 3.8°C [0.9-6.0], P < 0.0001). At 3 mm depth, temperature increases were reduced for all settings, but remained highest with Sequence_1 at 4 mL/min (42.5°C, ΔT: 5.5°C). At 7 mm depth, temperatures remained close to baseline. Both waveform and irrigation optimization independently and synergistically reduced tissue heating, with the Sequence_2 at 30 mL/min achieving the lowest thermal load at all depths.

Conclusion: This study confirms that PFA can induce relevant thermal effects, especially at the tissue interface. However, waveform optimization and active cooling significantly mitigate these effects. Such strategies to minimize thermal effects should be implemented in clinical practice to enhance procedural safety.

Aims: Left bundle branch area pacing (LBBAP) electrical performance is well documented. Nevertheless, the long-term mechanical implications, and differences between left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP), remain unclear. This study assessed mechanical performance of LBBAP in a mid- to long-term post-implantation setting and compared capture types.

Methods and results: In this prospective, single-centre study, 88 patients with preserved left ventricular ejection fraction and successful LBBAP underwent paired echocardiography during intrinsic and paced rhythm (median 18 months post-implant). Two-dimensional, speckle-tracking and myocardial work (MW) indices were analysed. Adjusted linear mixed-effects models for repeated measures compared LBBAP vs. intrinsic rhythm and LBBP vs. LVSP differences. Independent predictors of changes in MW indices were sought with multivariate regression. Left bundle branch area pacing showed lower left ventricular volumes than intrinsic rhythm and a decrease in global longitudinal strain (16.2% vs. 16.8%, P = 0.040). Global constructive work (2232.8 vs. 2028.8 mmHg%, P < 0.001) and global wasted work (266.2 vs. 219.1 mmHg%, P = 0.003) were higher during pacing, without differences in global work index (1607.8 vs. 1536.7 mmHg%, P = 0.171) or global work efficiency (GWE) (88.3% vs. 89.3%, P = 0.092). Between LBBP (n = 63) and LVSP (n = 25), no statistically significant differences were found in any parameter after covariate adjustment (all P > 0.28). In multivariate analysis, LVSP independently predicted modest GWE decrease.

Conclusion: In patients with preserved LVEF, LBBAP maintains global mechanical performance comparable to intrinsic rhythm while increasing constructive and wasted work. Mechanical performance is largely similar between LBBP and LVSP, supporting the physiological value of LBBAP regardless of capture type.