Incidence of silent cerebral lesions during pulsed field ablation for paroxysmal atrial fibrillation

Radiofrequency catheter ablation (RFCA) is a first-line treatment for paroxysmal atrial fibrillation (PAF). Complications such as silent cerebral lesion (SCL) may occur during ablation. Pulsed field ablation (PFA) is a non-thermal method thatablates cardiac tissue via irreversible electroporation. Limited studies have reported the incidence of SCL during PFA, with highly variable results. However, randomized controlled trials (RCTs) remain scarce. The objective of this study was to compare perioperative SCL incidence between PFA and RFCA, and to identify risk factors for SCL during PFA. In this prospective pilot RCT (ChiCTR2400088774), 62 patients with PAF were randomized 1:1 to undergo PFA or RFCA. Cerebral MRI (3.0 T) was performed preoperatively and 24–48h postoperatively. SCL was defined as a new acute brain lesion on MRI without neurological deficits. Baseline and surgical data of the patients were collected. SCL was detected post-procedure in 6.45% (2/31) in the RFCA group, 12.90% (4/31) in the PFA group. No statistically significant difference in the incidence of postoperative SCL was detected between the two groups (p = 0.67). Left atrium dimension (LAD), left atrial operation time (LAOT), left ventricular end-diastolic dimension (LVEDD), and total operation time (TOT) were significantly higher in SCL group than those in no-SCL group (p SCL incidence was 12.90% in the PFA group versus 6.45% in the RFCA group. While no statistically significant difference was detected between two groups, the numerically higher rate in the PFA group warrants larger studies to evaluate cerebral safety associated with PFA. This is the first prospective RCT comparing incidence of SCL during the perioperative period between PFA and RFCA with pre- and post-procedure MRI in both arms to exclude pre-existing acute lesions.The incidence of SCL in PFA group was double that in RFCA group (12.9% vs 6.45%). Although no statistically significant difference was detected, the trend toward higher SCL events in the PFA group might be considered.These findings indicated that prolonged procedural duration may be associated with a higher risk of SCL among PFA patients. This is the first prospective RCT comparing incidence of SCL during the perioperative period between PFA and RFCA with pre- and post-procedure MRI in both arms to exclude pre-existing acute lesions. The incidence of SCL in PFA group was double that in RFCA group (12.9% vs 6.45%). Although no statistically significant difference was detected, the trend toward higher SCL events in the PFA group might be considered. These findings indicated that prolonged procedural duration may be associated with a higher risk of SCL among PFA patients.