Repeat Pulse Field Ablations for Atrial Fibrillation are Safe and Efficacious

Results from the MANIFEST-REDO study have indicated the safety of repeat pulse field ablation (PFA) treatment for atrial fibrillation (AF).

Although pulmonary vein isolation (PVI) is the procedural standard for AF treatment, its durability after the initial procedure is limited. Multiple repeat treatments are necessary to avoid AF recurrence in a significant number of patients.1

PFA, an innovative cardiac ablation technique using high-voltage, ultrashort electrical pulses to form nanoscale pores in cardiac cell membranes, targets cardiac tissue without heating it, preserving nearby structures. As a result, it has been connected to greater efficacy than traditional thermal ablation methods.2

“However, there is limited data on procedural findings and especially on outcomes in patients undergoing re-ablation for AF or atrial tachycardia (AT) recurrence after an initial PF ablation for AF,” wrote Daniel Scherr, MD, division of cardiology, Department of Internal Medicine, Medical University of Graz, and colleagues. “This multicenter study (MANIFESTO-REDO) aims to evaluate the outcomes of catheter re-ablation in patients with AF/AT who previously underwent PF AF ablation using the pentaspline catheter.”1

Investigators in MANIFEST-REDO made use of the MANIFEST-PF, an international, prospective, patient-level registry collecting data from 24 European cities. Patients aged ≥18 years who underwent first-time PFA for AF between 2021 and 2024 were included in the study. Patients would then attend follow-up visits at 3, 6, and 12 months post operation, during which periods investigators assessed adverse events, AF-related symptoms, and potential recurrence of atrial arrhythmias.1

If patients exhibited symptomatic AF/AT recurrence >3 months after the initial surgery, they were eligible for a repeat ablation. RF ablation, cryoballoon ablation, PFA with the pentaspline catheter, alcohol ablation of the vein of Marshall, and/or focal PFA were utilized in the study.1

MANIFEST-REDO’s primary effectiveness endpoint was marked as freedom from documented AF/AT lasting ≥30 s after a 3 month blanking, without class I/III antiarrhythmic drugs (AADs) or symptoms. The secondary effectiveness endpoint involved freedom from AF/AT lasting ≥30s with or without the necessity for class I/III AADs.1

A total of 427 patients with a mean age of 64 years (standard deviation, 11), all of whom were scheduled for repeat ablation due to AF/AT recurrence after previous PF ablation for AF with the pentaspline catheter, were included in the study. Investigators noted the form of recurrent arrhythmias between patients: 219 exhibited paroxysmal AF (PAF), 128 had persistent AF (PersAF), and the remaining 80 had atrial tachycardia (AT).1

Patients underwent repeat ablation 279 +/- 171 days after the initial procedure. At the repeat operation, PV reconnection rates were 29% (left superior pulmonary vein, LSPV), 27% (left inferior pulmonary vein, LIPV), 32% (right superior pulmonary vein, RSPV), and 31% (right inferior pulmonary vein, RIPV). 45% of all patients saw PVs durably isolated at the beginning of the repeat procedure. The use of any form of preprocedural imaging, such as ICE, CT, and electroanatomic mapping, was associated with higher PVI durability (47% versus 37%; P = .036).1

The primary effectiveness endpoint was achieved by 65% of patients, although the 3 cohorts exhibited significant differences (PAF 65% vs PersAF 56% vs AT 76%; P = .04). Investigators found no association between time from initial to repeat ablation and the primary effectiveness endpoint. The secondary endpoint was achieved in 71% of patients (PAF 74% vs PersAF 61% vs AT 80%; P = .007).1

“The routine use of mapping for PFA-PVI may be helpful,” Scherr and colleagues wrote. “However, this needs to be investigated with fully integrated PF catheter systems that allow for contact assessment and lesion tracking.”1

References

1. Scherr D, Turagam MK, Maury P, et al. Repeat procedures after pulsed field ablation for atrial fibrillation: MANIFEST-REDO study. Europace. 2025;27(8):euaf012. doi:10.1093/europace/euaf012

2. Amin AM, Turkmani M, Al Barznji S, et al. Efficacy and Safety of Pulsed-Field Versus High-Power Short-Duration Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data. J Cardiovasc Electrophysiol. 2025;36(8):1762-1784. doi:10.1111/jce.16728