Evidence on pulsed-field ablation (PFA) for atrial fibrillation (AF) in patients with heart failure (HF) remains limited. A registry-based analysis published in the EP Europace assessed clinical outcomes following first-time pentaspline PFA in patients with AF, stratified by HF status and subtype.

 Consecutive patients enrolled in the ATHENA registry undergoing initial PFA were included. Participants were categorized into three groups: no HF, HF with preserved ejection fraction (HFpEF; left ventricular ejection fraction [LVEF] ≥50%), and HF with mildly reduced or reduced ejection fraction (HFmrEF/rEF; LVEF <50%).

The primary endpoint was freedom from documented atrial arrhythmias lasting >30 seconds after a 2-month blanking period. Antiarrhythmic drug (AAD) use was determined at physician discretion.

Among 1,224 patients, 68.5% had paroxysmal AF and 31.5% had persistent AF. HF was present in 14.4% of patients, including 3.3% with HFpEF and 11.1% with HFmrEF/rEF. At 1-year follow-up, Kaplan-Meier estimates showed overall freedom from atrial arrhythmias of 79.9%. Patients without HF had higher arrhythmia-free survival compared with those with HF (81.0% vs 73.3%; hazard ratio [HR] 1.5, 95% CI 1.1–2.1; p=0.0133).

In subgroup analyses, patients with paroxysmal AF without HF demonstrated higher arrhythmia-free rates than those with HF (82.2% vs 68.6%; HR 2.0, 95% CI 1.3–3.1; p=0.0028). No significant differences were observed among patients with persistent AF (77.9% vs 76.4%; HR 1.1, 95% CI 0.7–1.7; p=0.7065).

PFA demonstrated effectiveness across HF subgroups in AF management. Differences in outcomes were primarily observed in paroxysmal AF based on HF status.