Adding Posterior Wall Isolation to Pulmonary Vein Isolation Provides No Added Benefit in Persistent AF: Study
According to a new study among patients with persistent atrial fibrillation (AF) undergoing pulsed-field ablation (PFA), adding posterior wall isolation (PWI) to pulmonary vein isolation (PVI) did not significantly reduce recurrence of atrial tachyarrhythmias lasting ≥30 seconds compared with PVI alone. Secondary findings are hypothesis-generating and require confirmation in larger trials. The study was published in JAMA by Laurent R. and colleagues.
To comprehensively evaluate the efficacy and safety of the enlarged ablation sets, researchers performed an investigator-initiated, multicenter, randomized superiority study with blinded adjudication of endpoints at 6 specialist centers in Switzerland. The recruitment of 206 patients with symptomatic persistent AF took place from November 2023 to February 2025, while a one-year follow-up until February 2026 was completed. Patients were randomly divided into two groups in a 1:1 ratio, either to receive PFA-based PVI with PWI (n=102) or PFA-based PVI (n=104).
In order to obtain accurate assessment of the arrhythmias, each patient was equipped with an implantable cardiac monitor (ICM) after the procedure. The primary outcome was considered the first occurrence of atrial tachyarrhythmia of 30 seconds or longer between days 91 and 365 post-ablation, as adjudicated by an independent clinical event committee blinded to group allocation. Secondary outcomes included total atrial arrhythmia burden, recurrence rates according to duration, and 90-day safety composite for major surgical and vascular events.
Key findings:
- Atrial tachyarrhythmia lasting 30 seconds or longer recurred in 51 of 102 patients (50.6%) assigned to PVI with PWI compared to 63 of 104 patients (60.6%) assigned to PVI alone (rate ratio [RR], 0.75; 95% CI, 0.51–1.09; P = 0.13).
- Continuous ICM monitoring revealed a mean atrial arrhythmia burden of 6.9% in the PVI plus PWI group versus 11.0% in the PVI-alone group, representing a statistically significant absolute difference of −4.1 percentage points (95% CI, −8.0 to −0.2; P = 0.04).
- Across longer minimum episode durations, RRs favored PVI with PWI: 1 hour or longer (RR, 0.64; 95% CI, 0.41–0.99), 6 hours or longer (RR, 0.62; 95% CI, 0.38–1.03), 1 day or longer (RR, 0.37; 95% CI, 0.18–0.78), 2 days or longer (RR, 0.40; 95% CI, 0.18–0.88), and 7 days or longer (RR, 0.51; 95% CI, 0.22–1.23).
- Of 29 prespecified secondary outcomes, 22 showed no statistically significant differences between groups.
- The composite safety endpoint, comprising cardiac tamponade, persistent phrenic nerve palsy, stroke/TIA, vascular complications, atrioesophageal fistula, or death within 90 days, occurred in 2 patients assigned to PVI with PWI.
Posterior wall isolation using PFA in addition to PV isolation did not result in statistically significant decrease in recurrences of atrial tachyarrhythmia within 30 seconds in persistent AF patients. The findings made in the study clearly show that PVI should be the main target of intervention because the procedure of PWI did not significantly change the primary success rate in one year. Therefore, isolated PVI should be the standard approach using PFA in persistent AF.
Reference:
Roten L, Maurhofer J, Krisai P, et al. Pulmonary Vein Isolation Using Pulsed Field Ablation With vs Without Posterior Wall Isolation in Patients With Symptomatic Persistent Atrial Fibrillation: The PIFPAF-PFA Randomized Clinical Trial. JAMA. Published online August 29, 2026. doi:10.1001/jama.2026.17598
