The Pear Strategy for Two-Ring Pulmonary Vein Isolation: Antral and Sleeve Ablation Using a Balloon-in-Basket Pulsed Field Ablation Catheter.

BACKGROUND: Pulsed field ablation (PFA) has emerged as a promising energy source for atrial fibrillation (AF) catheter ablation. This study aimed to describe the adoption and workflow optimization of a novel balloon-in-basket PFA catheter using a two rings balloon and pear strategy for pulmonary vein isolation (PVI), the pear workflow. METHODS: Consecutive all-comer patients with AF underwent PFA using the balloon-in-basket PFA catheter under deep sedation. The pear workflow comprised a two-step PVI protocol: (1) four antral PFA applications guided by initial PV angiography to confirm PV occlusion and lesion overlap through rotational deployment, followed by (2) two distal, pear-shaped balloon applications targeting the PV sleeves. Three-dimensional electroanatomic mapping with impedance-based contact assessment was utilized. Procedural parameters, acute efficacy, and safety were analyzed. RESULTS: Fifty patients (62% paroxysmal AF, 42% female, mean age 68 ± 10 years) were enrolled. All PVs were successfully isolated. Median procedural and fluoroscopy times were 50 min (IQR 41-50) and 7.2 min (IQR 5.8-11.4), respectively, without significant change over the study course (50 vs. 47 min for patients 1-25 and 26-50, respectively, p = 0.26). Additional ablation was performed in four patients, and concomitant left atrial appendage closure was performed in three. No major or minor complications occurred. Transient phrenic nerve stunning was observed in two patients, resolving before procedure completion. CONCLUSION: The pear two-step strategy enables rapid, efficient, and safe PVI using a balloon-in-basket PFA catheter, which, despite its anatomically based design, offers procedural versatility through integrated mapping with a minimal learning curve.