Pulmonary vein isolation using a novel balloon-in-basket pulsed field ablation system: The Lübeck how-to protocol

Background Single-shot pulsed-field ablation (PFA) is increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). Although balloon-in-basket (BiB)-PFA-system integrates ablation and mapping into a single catheter, standardized procedural workflows remain limited. Objective To describe a standardized step-by-step workflow for AF-ablation using the BiB-PFA system and to evaluate procedural performance, acute safety, and the learning curve in clinical practice. Methods This prospective, single-center study included 40 consecutive patients undergoing index PVI using the BiB-PFA system at a tertiary high volume electrophysiology center. Procedures followed standardized protocol including balloon preparation, ultrasound-guided access, fluoroscopy-guided transseptal puncture, selective pulmonary vein (PV) angiography, and a structured two-step ablation approach for each vein. Posterior wall ablation (PWA) was performed in selected patients. Procedural metrics and acute complications were analyzed descriptively. Results Patients were 64.5[56.5;73.3] years old; 41% were female, and 57.5% had non-paroxysmal AF. Median procedure duration was 41.5[35.0;59.0] min, left atrial dwell time 27.5[25.0;36.0] min, and BiB dwell time 23.0[20.0;25.8] min. A median of 4 applications per PV was used. Reduced-energy delivery was required in 30% of right inferior and 25% of right superior PV. PWA was performed in 35% of patients using a median of 5 applications. No major intraprocedural complication occurred. Mean procedure duration decreased from 50.0 [38.0; 60.5] min in the first 10 cases to 34.5 [31.5; 52.0] min in the last 10 cases (p = 0.059). Conclusion A standardized BiB-PFA workflow enables efficient, safe, and reproducible PVI with optional PWA and can be rapidly implemented during early operator experience.