Introduction: Most studies have followed patients with persistent atrial fibrillation (PeAF) using 12-lead or 24-hour Holter electrocardiography, but this may overestimate the effectiveness of pulsed field ablation (PFA) in the treatment of PeAF. This study aimed to investigate the feasibility of PFA in patients with PeAF and follow-up using insertable cardiac monitoring (ICM) that can provide information on the actual status of atrial arrhythmia (AA) recurrence and AA duration after PFA. Methods and Results: We prospectively enrolled 49 patients with PeAF who underwent PFA strategy comprising superior vena cava isolation, pulmonary vein isolation, and posterior wall box isolation between December 2022 and January 2024. Acute electrical isolation rate was 100%. After median follow-up of 12.1 months, 29 patients (59.18%) had zero AA burden. Kaplan–Meier analysis show that the freedom from recurrence increased with arrhythmia duration thresholds, from 63.27% to 83.67% (duration ＞48 h vs. duration ＜2 min, P=0.040). Quality of life scores were significantly improved after PFA (6 months to baseline, P<0.001). Regression analysis revealed that larger low voltage areas in left atrium were associated with increased risk of AA recurrence (P= 0.046). Safety events occurred in two patients (one transient ischemic attack and one pseudoaneurysm). Conclusion: PFA is an effective modality for the treatment of patients with PeAF. With different arrhythmia duration thresholds, the rate of freedom from AA is quite different.
