Pulmonary Vein Isolation With Additional Ablation Is Associated With Worse Outcomes in Paroxysmal Atrial Fibrillation

Abstract 2317251, presented at Western Atrial Fibrillation Symposium 2026

Pulmonary vein isolation (PVI) represents the cornerstone ablation strategy for patients with paroxysmal atrial fibrillation (PAF). Although current guidelines recommend PVI alone in this population, adjunctive ablation beyond the pulmonary veins (PVI+) is still frequently performed during index procedures in routine clinical practice. Our objective was to compare recurrence, progression, and arrhythmia subtype outcomes in patients undergoing PVI alone versus PVI+ in the real world.Adults with PAF who underwent catheter ablation between January 2020 and July 2025 were identified using the TriNetX research network. Arrhythmia recurrence was defined by the need for repeat ablation, cardioversion, or antiarrhythmic drug therapy beyond a 3-month blanking period. Progression to persistent atrial fibrillation and development of atypical atrial flutter were also examined. Outcomes were analyzed using Kaplan–Meier methods with up to three years of follow-up.Among 18,756 eligible patients, 5,135 (27.4%) received an initial PVI+ strategy. After propensity score matching (5,020 patients per group), PVI+ was associated with a significantly higher risk of arrhythmia recurrence compared with PVI alone (HR 1.21, 95% CI 1.09–1.33; p = 0.0003). Patients undergoing PVI+ experienced increased rates of repeat ablation (HR 2.10, 95% CI 1.68–2.62; p < 0.0001) and cardioversion (HR 1.29, 95% CI 1.06–1.57; p = 0.01), while post-procedural antiarrhythmic drug use did not differ between groups. Progression to persistent AF was more frequent following PVI+ (HR 1.31, 95% CI 1.18–1.46; p < 0.0001). Notably, adjunctive ablation was also associated with a markedly higher incidence of atypical atrial flutter (HR 2.63, 95% CI 1.97–3.50; p < 0.0001).Despite guideline recommendations, additional ablation beyond pulmonary vein isolation remains common during first-time ablation for paroxysmal atrial fibrillation. In real-world practice, this strategy is associated with poorer arrhythmic outcomes, including increased recurrence, repeat interventions, atrial flutter, and progression to persistent atrial fibrillation.