AIMS: Initial clinical studies of pulsed field ablation (PFA) to treat atrial fibrillation (AF) indicated a >90% durability rate of pulmonary vein isolation (PVI). However, these studies were largely conducted in single centres and involved a limited number of operators. We aimed to describe the electrophysiological findings and outcomes in patients undergoing repeat ablation after an initial PF ablation for AF. METHODS AND RESULTS: In the MANIFEST-REDO study, we investigated patients who underwent repeat ablation due to clinical recurrence-AF or atrial tachycardia (AT)-following first-ever PVI with a pentaspline PFA catheter (Farawave, Boston Scientific Inc.). At 22 centres, 427 patients (age 64 ± 11 years; 37% female) were included. Of note, the recurrent arrhythmia leading to the repeat ablation was paroxysmal AF (51%), persistent AF (30%), or AT (19%). At the repeat procedure, the PV reconnection rates were 30% (left superior pulmonary vein), 28% (left inferior pulmonary vein), 33% (right superior pulmonary vein), and 32% (right inferior pulmonary vein). In 45% of patients, all PVs were durably isolated at the beginning of the repeat procedure, with the previous use of any imaging or mapping modality being univariately associated with durable PVI. After a post-redo follow-up period of 284 (90-366) days, the primary effectiveness endpoint (freedom from documented AF/AT lasting ≥30 s after 3-month blanking without class I/III antiarrhythmic drugs or symptoms) was achieved in 65% of patients, with significant differences between groups (PAF 65% vs. PersAF 56% vs. AT 76%; P = 0.04). Persistent AF as recurrent arrhythmia after the initial PFA ablation predicted AT/AF recurrence after repeat ablation [hazard ratio 1.241 (95% confidence interval 1.534-1.005); P = 0.045]. The procedural complication rate was 2.8%. CONCLUSION: In repeat procedures for AF/AT performed after an index procedure with PFA for AF, PV reconnections are not uncommon. Repeat procedures can be performed safely and with an acceptable subsequent success rate.

Asklepios Hospital St Georg Hamburg Germany

Cardiology Department Na Homolce Hospital Homolka Hospital Prague Czech Republic

Catharina Hospital Eindhoven The Netherlands

Clinic for Electrophysiology Herz und Diabeteszentrum NRW Ruhr University Bochum Bad Oeynhausen Germany

Department for Cardiovascular Diseases University Hospital Center Split Split Croatia

Department for Electrophysiology Heart Center University Hospital of Cologne Cologne Germany

Department of Cardiology and Angiology Medical Center and Faculty of Medicine University of Freiburg Freiburg Germany

Department of Cardiology and Vascular Medicine West German Heart and Vascular Center Essen University Duisburg Essen Duisburg Germany

Department of Cardiology Herlev Gentofte University Hospital Hellerup Denmark

Department of Cardiology Jessa Hospitals Hasselt Belgium

Department of Cardiology Rouen Hospital Rouen France

Department of Cardiology University Hospital Rangueil Toulouse France

Department of Cardiology University of Groningen University Medical Center Groningen Groningen The Netherlands

Department of Medicine and Cardiology Goethe University Frankfurt Germany

Department of Rhythmology Cardiology and Intensive Care Medicine Asklepios Klinik Altona Hamburg Germany

Division of Cardiology Department of Internal Medicine Medical University of Graz Auenbruggerplatz 15 8036 Graz Austria

German Center for Cardiovascular Research DZHK Partner Site Rhine Main Germany

German Center for Cardiovascular Research Partner Site Hamburg Kiel Lübeck Lübeck Germany

Heart Center Bad Neustadt Rhoen Clinic Campus Bad Neustadt Bad Neustadt an der Saale Germany

Heart Rhythm Department Clinique Pasteur Toulouse France

I2MC INSERM UMR 1297 Toulouse France

Icahn School of Medicine at Mount Sinai New York NY USA

IHU LIRYC CHU Bordeaux University of Bordeaux Bordeaux France

IKEM Institute for Clinical and Experimental Medicine Prague Czech Republic

Inselspital Bern University Hospital University of Bern Bern Switzerland

Neuron Medical Brno Czech Republic

University Heart and Vascular Center University Medical Center Hamburg Eppendorf Hamburg Germany

University Heart Center Lübeck Department of Rhythmology University Hospital Schleswig Holstein Germany

Europace. 2025 Feb 5;27(2):euaf014. doi: 10.1093/europace/euaf014. PubMed

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