Pulsed Field Ablation as Initial Therapy for Persistent Atrial Fibrillation.

Summary

In previously untreated persistent atrial fibrillation, first-line PFA achieved higher 12-month treatment success than antiarrhythmic-drug therapy, with a device/procedure-related serious adverse event rate of 5.1%. Continuous insertable monitoring strengthened event ascertainment.

Key Findings

• First-line PFA improved 12-month treatment success vs antiarrhythmic drugs (Kaplan–Meier 56% vs 30%; HR for failure 0.46).
• All patients had insertable monitors, enabling robust detection of arrhythmia recurrence and treatment failures.
• Device/procedure-related serious adverse events occurred in 5.1% of PFA-treated patients.

Clinical Implications

For suitable persistent AF patients, earlier referral for PFA may reduce arrhythmia recurrence versus stepwise antiarrhythmic drug trials; programs should prepare for PFA capacity and safety surveillance.

Limitations

• Open-label comparison of ablation vs pharmacotherapy may introduce performance bias
• Follow-up limited to 12 months; long-term durability and rare adverse events remain uncertain

Future Directions

Head-to-head comparisons of PFA versus thermal ablation as first-line therapy, cost-effectiveness analyses, and longer-term durability and safety registries are warranted.