Sandrine Venier

Pulsed field ablation (PFA) has emerged as a transformative technology in cardiac electrophysiology, offering a potentially superior safety profile compared with thermal ablation due to its non-thermal mechanism of irreversible electroporation. Clinical experience confirms a substantial reduction in traditional complications such as pulmonary vein stenosis, atrio-oesophageal fistula, and permanent phrenic nerve injury, though PFA introduces a distinct spectrum of physiologic effects requiring consideration. Coronary vasospasm is the most characteristic phenomenon, ranging from transient, subclinical constriction to rare ischaemic or arrhythmic events; mitigation relies on coronary anatomical awareness, optimized lesion placement, and prophylactic vasodilators. Haemolysis, caused by red blood cell electroporation, varies with catheter design and pulse burden and is typically mild, though high exposure and inadequate hydration may rarely lead to acute kidney injury. Silent cerebral lesions could result from procedural and/or energy-related factors, including gas formation, air ingress, catheter manipulation, and anticoagulation management, with uncertain long-term clinical impact but opportunities for technique-driven reduction. Interactions between PFA and cardiac implantable electronic devices are system- and context-dependent, with monopolar configurations and catheter-lead proximity influencing the risk of transient interference and rare permanent damage.

Aims: Obesity is associated with atrial fibrillation (AF), atrial remodelling, and cardiometabolic comorbidities. Whether baseline body mass index (BMI) influences procedural safety and effectiveness of pulsed-field ablation (PFA) remains uncertain. We evaluated the association of baseline BMI with procedural characteristics, periprocedural safety, and 1-year arrhythmia recurrence after first-time PFA for AF. Methods and results: FRANCE-PFA is a nationwide registry including consecutive patients undergoing first-time AF ablation with a pentaspline PFA catheter. Patients with available BMI were categorized as <25, 25 to <30, 30 to <35, or ≥35 kg/m2. Periprocedural complications and 1-year atrial arrhythmia recurrence were assessed across BMI categories. Among 5223 patients, BMI was available in 4573 (87.6%). Higher BMI was associated with greater cardiometabolic burden, more persistent AF, larger atria, and more extensive ablation strategies, including fewer pulmonary vein isolation-only procedures and more additional lesion sets (all P < 0.001). Periprocedural complications remained infrequent (1.0%), with no significant difference across BMI categories. At 1 year, recurrence was driven mainly by AF type rather than obesity. Within paroxysmal and non-paroxysmal AF, recurrence rates were comparable between patients with BMI < 35 and ≥35 kg/m2 (13.8% vs. 9.1% and 22.9% vs. 23.3%, respectively; log-rank P = 0.925). Severe obesity was not associated with recurrence after multivariable adjustment (HR, 0.86; 95% CI, 0.65–1.14; P = 0.299), with similar findings when BMI was analysed continuously. Conclusion: In this nationwide PFA cohort, higher BMI identified a more advanced AF phenotype and more extensive ablation strategies but was not independently associated with periprocedural complications or 1-year arrhythmia recurrence.

BACKGROUND: Pulsed field ablation (PFA) is a novel and rapidly expanding energy for the ablation of atrial fibrillation (AF). The relationships between the characteristics of pulmonary vein (PV) and extra-PV PFA applications, and the type of arrhythmia recurrence or durable lesion observed during redo procedures remain unclear. METHODS: In this substudy of the FRANCE PFA national exhaustive multicentric registry, we collected detailed data on PFA applications delivered during the initial AF ablation procedure. Among patients with arrhythmia recurrence undergoing redo procedures with 3-dimensional mapping (n=145), we analyzed the type of recurrence, rates of durable PV isolation (PVI), and the presence of complete block over the ablation lines. RESULTS: Recurrent arrhythmias comprised AF in 58%, atrial tachycardia in 23%, and typical atrial flutter in 9%. AF was less frequently observed when initial ablation targeted extra-PV areas (45 versus 71%; P =0.01) and when a 35-mm diameter catheter was used for PVI only (50 versus 77%; P =0.01). Complete durable PVI was observed in 42% of patients (69% to 76% for each separate PV), and durable roof/PW and mitral isthmus blocks were observed in 62% and 31% of cases, respectively. The rate of durable PVI increased with the number of PFA applications ( P 12 applications. Similarly, roof/PW block rates increased to 88% with >16 applications ( P 12 PFA applications per PV and >16 for the roof/PW. Long-term durability of mitral isthmus block was poor using the Pentaspline PFA catheter.

BACKGROUND: GLP-1 (glucagon-like peptide-1) receptor agonists (GLP-1RAs), initially developed for glycemic control in type 2 diabetes, have shown cardiometabolic benefits including weight loss, improved endothelial function, and reduced inflammation. Recent data suggest potential anti-arrhythmic effects via modulation of atrial substrate and autonomic tone. Their impact on obese, nondiabetic patients remains underexplored. This study examines whether GLP-1RA use is associated with reduced atrial fibrillation recurrence after catheter ablation in obese patients, using real-world data from a large multicenter database. METHODS: We conducted a retrospective cohort study using the TriNetX research network, which contains de-identified electronic health records from >100 million patients. Adult patients (age ≥18 years) with obesity (body mass index >30 kg/m²) who underwent atrial fibrillation (AF) ablation between January 2015 and January 2025 were eligible. The cohort was divided into GLP-1RA users (n=3350) and nonusers (n=3350), with 1:1 propensity score matching performed across 82 clinical and demographic variables, including age, sex, race, AF subtype, cardiovascular comorbidities, and baseline medications. RESULTS: During a median follow-up of 2 years (interquartile range, 0.8–3.2) AF recurrence was significantly lower in GLP-1RA users versus non users (6.66% versus 7.72%; hazard ratio [HR], 0.82 [95% CI, 0.76–0.88]; P P =0.01). Risk of all-cause mortality was lower in the GLP-1RA group (HR, 0.73 [95% CI, 0.59–0.91]; P =0.01) HF hospitalization (HR, 0.80 [95% CI, 0.71–0.90]; P P =0.001) were also significantly lower with GLP-1RA use. No significant difference was found for redo ablation. CONCLUSIONS: In a large real-world cohort of obese patients undergoing catheter ablation for AF, GLP-1RA therapy was associated with lower risks of AF recurrence, progression to permanent AF, cardiovascular hospitalizations, and mortality.

Aims: Leadless pacemakers (LLPs) offer a valuable option for selected patients requiring ventricular pacing. However, data on revision procedures—defined as any intervention on an implanted LLP to correct dysfunction or upgrade the system, with or without removal—remain scarce. This study aimed to evaluate the real-world incidence, characteristics, and outcomes of LLP revisions, with particular emphasis on the feasibility and safety of removal. Methods and results: This multicentre retrospective study involved 46 French centres performing LLP implantations between 2015 and 2023. Among 8994 Micra LLPs implanted, 100 revision procedures (1.1%) were performed in 100 patients, including 73 Micra VR and 27 Micra AV devices, at a median follow-up of 229 (68.5–629.8) days. Seventy revisions were managed without device removal, while 30 involved removal. Revision indications included device upgrade (55%), high pacing threshold (33%), battery depletion (3%), ventricular arrhythmias (3%), and miscellaneous causes (6%). No significant differences were observed in pacing indications, implantation characteristics, or initial device indication between the two groups. Revisions occurred significantly earlier in the removal group than in the group without removal [median 81.5 (8–211.5) days, vs. 334 (130.25–882.5) days, P < 0.001], with 80% occurring within 1 year. Device removal was successful in 97% of cases (one failure at 157 days of follow-up), with no major complications reported. Conclusion: LLP revisions are infrequent and predominantly managed without device removal. However, given the high procedural success rate and the low complication rate, device removal appears to be underutilized and should be considered more frequently on a case-by-case basis.