- Design
- Randomised superiority trial, blinded endpoint adjudication, continuous loop-recorder monitoring
- Population
- 206 patients with symptomatic persistent AF
- Primary outcome
- Atrial tachyarrhythmia recurrence ≥30 s, days 91–365
- Effect
- 50.6% vs 60.6%, RR 0.75 (95% CI 0.51 to 1.09)
PIFPAF-PFA randomised 206 patients with symptomatic persistent AF at six Swiss centres to pulsed field PVI with or without posterior wall isolation. Every patient had an implantable loop recorder, and recurrence of 30 seconds or more between days 91 and 365 was adjudicated blind.
Recurrence occurred in 50.6% with posterior wall isolation and 60.6% without (RR 0.75, 0.51 to 1.09). AF burden was lower, 6.9% against 11.0%, and longer episodes (1 day or more) were less frequent. Safety events occurred in 2 patients, both in the posterior wall group. Most secondary endpoints did not differ.
The trial is small and the direction favours posterior wall isolation, but it does not establish it as routine. Continuous monitoring also shows how often 'success' after persistent AF ablation still means some recurrence.
- Offer PVI alone as the standard first procedure in persistent AF
- Set expectations: about half of patients had some recurrence at one year on continuous monitoring
- Judge outcome by symptoms and burden, not only by any recurrence
- Posterior wall isolation remains a reasonable option at redo procedures
Why it matters
Pulsed field energy made posterior wall isolation easy to add; this trial shows it is not yet proven worth adding.
Don't overread it
The lower AF burden and longer-episode results are secondary endpoints among 29, and are hypothesis-generating.
The statistics, in plain English
A rate ratio of 0.75 with an interval of 0.51 to 1.09 is compatible with a 49% reduction or a 9% increase, so the trial is inconclusive rather than negative. With 29 secondary endpoints, a few will reach P < 0.05 by chance, which is why the burden result needs a larger trial.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for cardiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free