First-line therapy for persistent atrial fibrillation with anatomically guided third-generation laser balloon ablation: multicentre study results with continuous rhythm monitoring

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Abstract Background Transcatheter ablation for atrial fibrillation (AF) prevents recurrences, reduces AF burden, and improves quality of life. Robust evidence supports its use as a first-line therapy for rhythm control, demonstrating a comparable risk of adverse events to antiarrhythmic drug (AAD) therapy. Anatomically guided third-generation laser balloon ablation provides a safe and effective option, offering excellent long-term outcomes in both paroxysmal and persistent AF cases. Aims This study presents the first prospective multicentre assessment of third-generation laser balloon ablation as an initial therapy for paroxysmal and persistent AF, conducted without acute confirmation of pulmonary vein isolation Methods We conducted a multicentre study in Italy involving patients with either paroxysmal or persistent AF, who had not previously undergone rhythm control therapy. Participants were treated with third-generation laser balloon ablation targeting pulmonary vein isolation. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence following a 3-month blanking period (BP), monitored using implantable cardiac monitors (ICM). Results Among the 113 patients (71% male; mean age 60.2 ± 10.9 years) who underwent ablation, 76% had paroxysmal AF. The mean left atrial volume/body surface area was 33.9 ± 7.0 mL/m², with 7% of patients (n=8) presenting moderate left atrial dilation. No significant periprocedural or follow-up complications occurred. At an average follow-up of 35.7 ± 9.6 months, freedom from ATa recurrence was achieved in 77% of patients with paroxysmal AF and 59% with persistent AF. Recurrences during the BP [hazard ratio (HR) = 2.334, P = 0.030] and left atrial dilation (HR = 2.843, P = 0.035) were independent predictors of recurrence. Conclusions Anatomically guided third-generation laser balloon ablation is a safe and effective first-line therapy for paroxysmal and persistent AF, providing strong clinical outcomes with nearly three years of ICM-based follow-up.

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