# Wall Thickness‐Guided vs. Voltage‐Guided Pulmonary Vein Isolation for Atrial Fibrillation

## TL;DR

This study compares two methods for treating atrial fibrillation and finds that one method results in fewer complications during the procedure.

## Contribution

The study introduces a new approach using wall thickness to guide ablation, showing better results than the traditional voltage-guided method.

## Key findings

- The wall thickness-guided group had a lower incidence of PV gaps compared to the voltage-guided group.
- Both ablation strategies were performed without procedural complications.
- Multivariable analysis showed wall thickness-guided ablation was more effective in preventing PV gaps.

## Abstract

The efficacy and safety of tailored pulmonary vein isolation (PVI) guided by either left atrial wall thickness (LAWT) or bipolar voltage remain unclear.

The aim of this prospective study was to evaluate the efficacy and safety of each ablation strategy.

We conducted a prospective analysis of 97 patients with non‐valvular atrial fibrillation (AF) who underwent an initial RF catheter ablation procedure known as an extensive encircling PVI. Fifty patients underwent PVI using a wall thickness (WT)‐guided approach using ADAS 3D software and 47 patients using a voltage‐guided approach. In each strategy, high‐power short‐duration (HPSD) ablation was applied to regions with increased LAWT or elevated bipolar voltage, respectively, while very high‐power short‐duration (vHPSD) ablation was delivered to the remaining regions.

The first‐pass PVI rate tended to be higher in the WT‐guided group compared to the Voltage‐guided group (43 [86%] vs. 34 [72%], p = 0.09), and the incidence of acute PV reconnection (APVR) tended to be lower (5 [10%] vs. 11 [23%], p = 0.07). The proportion of patients with PV gaps (defined as the combined occurrence of first‐pass failure and/or APVR) was significantly lower in the WT‐guided group (10 [20%] vs. 18 [38%], p = 0.04). The multivariable‐adjusted analysis demonstrated that WT‐guided ablation was significantly more effective than Voltage‐guided ablation in preventing PV gaps. Both ablation strategies were performed without any procedural complications.

WT‐guided ablation was associated with a significantly lower incidence of PV gaps than a conventional bipolar voltage‐guided strategy.

Wall‐thickness guided pulmonary vein isolation using integrated pre‐procedural CT imaging and ADAS 3D software was associated with a significantly lower incidence of PV gaps than a conventional bipolar voltage‐guided strategy despite similar 1‐year clinical outcomes. These findings support individualized, left atrial wall thickness–based strategies in the high‐power RF ablation era.