- Design
- Multicentre randomised superiority trial, blinded adjudication
- Population
- 206 patients with symptomatic persistent AF
- Primary outcome
- Atrial tachyarrhythmia recurrence days 91–365 on implantable monitor
- Effect
- 50.6% vs 60.6%; RR 0.75 (95% CI 0.51–1.09), P = 0.13
PIFPAF-PFA randomised 206 patients with symptomatic persistent atrial fibrillation at six Swiss centres to pulsed field pulmonary vein isolation (PVI) with or without posterior left atrial wall isolation. Every patient received an implantable loop recorder, so recurrence was measured continuously and adjudicated blind.
Atrial tachyarrhythmia of 30 seconds or longer recurred between days 91 and 365 in 50.6% with posterior wall isolation and 60.6% with PVI alone (RR 0.75, 95% CI 0.51–1.09; P = 0.13). Mean arrhythmia burden was lower (6.9% vs 11.0%), and recurrences lasting a day or longer were less frequent, but 22 of 29 secondary outcomes did not differ.
The primary result is neutral. The burden and longer-episode signals are interesting but come from a small trial with many secondary tests, and the authors call them hypothesis generating.
- Pulmonary vein isolation alone remains a reasonable first ablation strategy in persistent AF.
- Expect recurrence in about half to 60% of persistent AF patients within a year on continuous monitoring.
- Counsel patients that 30-second recurrences are common and do not necessarily mean the ablation failed.
- Ask about arrhythmia burden and symptoms, not just any recurrence, when judging ablation success.
- Posterior wall isolation by pulsed field added two safety events in this trial; weigh it case by case.
Why it matters
It tempers the move to extend lesion sets just because pulsed field energy makes them easier.
Don't overread it
The secondary burden benefit comes from one of 29 end points in a 206-patient trial.
The statistics, in plain English
A rate ratio of 0.75 with a confidence interval of 0.51 to 1.09 crosses 1.0, so the trial could not exclude no effect. With 29 secondary outcomes, a few will look significant by chance; the burden difference (P = 0.04) is borderline and should be read as a lead, not a finding.
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