Integrating Atrial Fibrillation Mapping Into the Pulsed Field Ablation Procedure

Interview With David Krummen, MD

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David Krummen, MD, Professor of Clinical Medicine at University of California San Diego, discusses his upcoming presentation at Western AF, including current challenges and future directions for advancing or improving the integration of mapping and PFA.

What are you most looking forward to at the 2025 Western Atrial Fibrillation (AF) Symposium?

I think Western AF is an amazing opportunity to meet with and discuss emerging technologies and the latest clinical trials with experts in the field. Just recently, several clinical trials were announced that I think have huge implications for our management of this very common clinical arrhythmia, AF. 

Tell us about the focus of your upcoming presentation at Western AF 2025. 

The title of my talk is “Integrating AF Mapping Into the Pulsed Field Ablation (PFA) Ablation Procedure.” The background of this topic is that in prior landmark studies, including STAR AF II, different ablation strategies were compared, specifically, pulmonary vein isolation (PVI) was compared to empiric ablation, including linear lines and ablation of complex fractionated atrial electrograms. The results of the STAR AF II trial showed no benefit to this additional empiric ablation, and this kind of has served as the standard of care for AF-targeted therapies. Two randomized clinical trials, TAILORED-AF and FLOW-AF, were recently published, and for the first time showed potential benefits of mapping and ablating AF drivers. So, I will be discussing potentially incorporating these new technologies into the AF ablation workflow.

What are some of the current challenges in integrating AF mapping with PFA?

There are a number of challenges, including catheters, workflow, and potential costs of these technologies. With respect to catheters, the PFA single-shot catheters are excellent for achieving PVI with just a few ablation applications. However, because of their design, there are limitations in terms of performing geometry creation, electrogram mapping, and identification of potential non-PV drivers. A second challenge is workflow. The use of single-shot catheters necessitates a particular workflow, and if additional mapping is desired, a separate mapping catheter would have to be introduced to potentially create the geometry, record electrograms, and perform the mapping procedure. Both of these challenges lead to increases in cost and overall procedure time. So, those are some of the challenges faced when we try to integrate these technologies into the PFA ablation workflow.

How does the integration of mapping and PFA for the treatment of AF impact clinical practice, particularly in terms of improving patient outcomes, reducing recurrence rates, or enhancing procedural efficiency?

The integration of these technologies has significant potential to help over 40% of patients, particularly those with persistent AF or redo ablation procedures for whom the standard approach does not achieve the clinical and desired outcome. Specifically, in the TAILORED-AF study, there was an improvement in freedom from AF at 1-year follow-up. The FLOW-AF study, which only enrolled patients with redo procedures, also showed an improvement in freedom from AF. So, successfully incorporating these technologies and other technologies has significant implications in reducing AF recurrence rates. 

Importantly, the PFA catheters have reduced rates of complications, specifically, atrial esophageal fistula, PV stenosis, and phrenic nerve injury. So, to be able to combine these mapping technologies with these PFA catheters could lead to significantly better outcomes in terms of safety and procedural efficacy.

Tell us about potential future directions for advancing or improving the integration of mapping and PFA.

Future directions would be to devise workflows that allow the rapid mapping and identification of non-PV drivers, either with existing catheters or technologies, or to be able to identify ways to combine mapping and identification of non-PV drivers, while at the same time, another operator could be performing the ablation on the contralateral side of the left atrium. So, those are two potential ways to do it. There are other technologies that might be able to map non-PV AF drivers, and clinical trials involving these technologies are underway. 

What are the take-home messages you would like viewers to leave with?

First, I'd like to recommend that viewers be open to potentially doing non-PV AF driver mapping. Some of these technologies have significant potential to identify drivers in regions that have not traditionally been considered for AF mapping and ablation, such as drivers in the right atrium or drivers in the septal wall of the left atrium, not traditionally targeted by current therapies. I would also encourage them to continue to innovate, both in their workflows and in their delivery of care, and share those innovations with the rest of the electrophysiology community so that we can all learn and work together to improve patient outcomes.

The transcripts have been edited for clarity and length.