Real‐Time 3D Mapping Corrects Fluoroscopic Misperception During Pulmonary Vein Isolation by Pulsed Field Ablation

ABSTRACT

Background

Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) is mainly guided by fluoroscopy. A novel electroanatomical module enables real‐time 3D mapping (3D‐EAM) integrated with the PFA catheter.

Objectives

To assess the contribution of 3D‐EAM to pulmonary vein (PV) targeting accuracy and lesion coverage during PFA.

Methods

Among 66 consecutive prospective cases, two sequential phases were conducted: a 3D‐blinded mapping phase (n = 21), in which anatomical maps were created but withheld from operators, and a real‐time 3D‐EAM guidance phase (n = 45), where live mapping was used during ablation. A retrospective cohort of fluoroscopy‐only PFA procedures (n = 77) served as a control. Lesion coverage and procedural metrics were compared across groups, and post‐procedural operator assessments were collected in the 3D‐blinded phase.

Results

In the 3D‐blinded phase, 5 of 21 procedures (23.8%) failed to isolate at least one PV during the first attempt. Additionally, 47.6% of operators reported they would have altered their strategy using 3D‐EAM guidance. Overall lesion coverage was judged satisfactory in 77 of 84 PVs (91.5%). In the real‐time 3D‐EAM phase, no veins were missed. Compared with fluoroscopy‐only and 3D‐blinded procedures, 3D‐EAM guidance significantly reduced the number of PVI applications (33.6 ± 7.8 vs. 38.4 ± 9.0 and 39.3 ± 10.5; p = 0.007) but increased left atrial dwell time (23.6 ± 7.2 vs. 16.7 ± 4.3 min; p < 0.001).

Conclusions

Real‐time 3D‐EAM guidance improved PV targeting, reduced unnecessary applications, and eliminated missed veins. Integration of 3D mapping into PFA workflows is safe, feasible, and may enhance procedural quality. Larger studies are warranted to determine effects on long‐term arrhythmia recurrence and durability.

In a three‐phase comparison (fluoroscopy‐only, 3D‐blinded, and real‐time 3D‐EAM), 23.8% of blinded procedures missed at least one pulmonary vein. Real‐time 3D mapping eliminated missed veins and reduced PVI applications. 3D‐EAM, three‐dimensional electroanatomical mapping; CT, computed tomography; LA, left atrium; PV, pulmonary vein.

1. Introduction

Pulsed field ablation (PFA) has emerged as a non‐thermal modality for pulmonary vein isolation (PVI), with favorable safety and efficacy [1, 2, 3]. In Europe, the pentaspline catheter is predominantly guided by fluoroscopy, unlike cryoballoon ablation, where venography provides immediate anatomical feedback. This approach relies on indirect anatomical perception and may be misleading.

While the efficacy and safety of PFA have been established [4, 5], the potential contribution of real‐time integrated 3D mapping to procedural strategy and lesion coverage remains unclear [6, 7]. In particular, whether prior anatomical mapping influences the completeness and quality of PVI in PFA workflows has not been formally assessed.

We conducted this proof‐of‐concept study to determine whether integrated 3D mapping can correct fluoroscopic misperception and improve lesion coverage during PFA.

2. Methods

2.1. Study Design

We conducted a prospective, observational study at Clermont‐Ferrand University Hospital. All patients referred for atrial fibrillation ablation by PFA were enrolled if they were over 18 years old, provided informed consent for data collection, and had no prior PVI procedure. The first 66 consecutive atrial fibrillation ablation procedures performed at our center using an integrated 3D electroanatomical mapping system (Opal, Boston Scientific) were included. These 66 cases were conducted in two sequential phases. In the initial “3D‐blinded” phase (n = 21), a 3D anatomical map of the left atrium was created but not displayed to the ablating operator. In the subsequent “real‐time 3D‐EAM” phase (n = 45), the electroanatomical map was built and used live to guide catheter positioning and lesion delivery. These patients were compared to a historical cohort, the “Fluoroscopy group” (n = 77). To minimize the impact of operator experience or procedural evolution, the control group was limited to the 8‐week period preceding the adoption of the 3D mapping system.

The study was approved by the local Ethics Committee (IRB number 2025‐CF465) in compliance with the French regulations on individual data protection.

2.2. PVI by PFA: Procedural Specificities

Transseptal puncture was performed under transesophageal echocardiography guidance, after exclusion of left atrial thrombus. PVI was performed following manufacturer recommendations and published methodology for the pentaspline PFA catheter [8]. Each pulmonary vein (PV) was treated with at least eight applications: four in the “basket” configuration and four in the “flower” configuration. Fluoroscopic guidance systematically included both anteroposterior and steep left anterior oblique (LAO 25°–40°) projections to distinguish right PVs, in accordance with standard practice. Right anterior oblique (RAO 20°–30°) projections were also used when necessary. Catheter positioning and additional applications were determined by the operator under fluoroscopic guidance and atrial electrogram interpretation. At the operator's discretion, posterior wall ablation could be delivered during the procedure. These cases were retained for the analysis of procedural time and fluoroscopy exposure. For the qualitative evaluation of lesion coverage, however, segments affected by extra‐PVI ablation were excluded from analysis. The procedures were performed by four operators with over 5 years of experience performing atrial fibrillation ablation using PFA or cryoballoon techniques. Their cumulative PFA procedural volume exceeded 1200 cases. None of the operators had prior experience with the integrated 3D mapping system at the time of this phase. Two of them had limited prior experience with real‐time electroanatomical mapping.

When available, a preprocedural CT was obtained to visualize left atrial and PV anatomy and to exclude left atrial appendage thrombus. The CT reconstruction was displayed on a parallel screen during all procedure as an anatomical reference; CT–fluoroscopy fusion was not performed. The CT served as a static anatomical reference rather than a live navigation tool.

2.3. 3D‐Blinded PFA (n = 21): Procedural Specificities

In the phase “3D‐blinded,” a 3D anatomical map of the left atrium was acquired prior to ablation using the PFA catheter, and PVI was performed with the operator blinded to the 3D map. Prior to the procedure, 19/21 (90.5%) patients underwent a cardiac computed tomography scan to obtain a high‐resolution 3D reconstruction of the left atrial anatomy. Operators had full access to the CT and fluoroscopy but were blinded only to the 3D electroanatomical map.

Each procedure was structured into two distinct steps (Figure 1):

Figure 1.

Flow chart summarizing the three study phases (fluoroscopy‐only, 3D‐blinded, and real‐time 3D‐EAM), including operator roles and blinding procedures.

(i) A mapping team (one physician dedicated to mapping and one engineer) performed a 3D reconstruction of the left atrium prior to ablation with the pentaspline catheter. Only anatomical data were collected during mapping; electrograms were intentionally excluded and not used to generate the map. This mapping operator created the anatomical reconstruction but did not perform any blinded ablation procedures.

(ii) A second operator and a second engineer, blinded to the 3D map, performed PVI under fluoroscopic guidance. During the 3D‐blinded phase, ablating operators were fully blinded to the 3D maps until they had completed all their cases. The ablating operator was notified in real time only if any PVs had not been addressed by the end of the procedure. PVI was verified by mapping with the PFA pentaspline catheter and exit block assessment by opening the catheter fully inside the PV. Each operator carried out five procedures, with one performed six. All procedures were video recorded.

After all procedures were completed, the 3D maps and video recordings were reviewed retrospectively by two operators: the physician who performed the ablation and a second operator who had not participated in the procedure and was blinded to fluoroscopic images and lesion delivery. They assessed lesion coverage and whether their ablation strategy would have differed if the 3D map had been available.

Management of missed or suboptimal PV ablation:

At the end of each blind procedure, the mapping operator verified whether all PVs had been isolated. When a vein had not been targeted, the ablating operator was immediately informed and attempted to cannulate and isolate the vein using fluoroscopic guidance only. If the vein could not be confidently located under fluoroscopy, the mapping operator (who had access to the 3D map) guided catheterization and completed the isolation.

When all PVs were successfully isolated but the lesion set was judged suboptimal on retrospective review, no optimization was performed. Operators were not allowed to access any 3D maps, videos, or procedural feedback until their full blinded sequence was completed.

Posterior wall ablation, when performed at the operator's discretion, was included in procedural time and fluoroscopy analyses but excluded from the lesion coverage evaluation. As roof ablation was not performed in our cohort, only posterior wall lesions are reported and analyzed separately.

2.4. Real‐Time 3D Guidance PFA (n = 45): Procedural Specificities

In the “3D‐EAM‐guided” phase (n = 45), the 3D mapping system was used routinely and in real time to guide the ablation. Mapping and ablation were performed simultaneously, without a dedicated mapping phase. The electroanatomical map was progressively constructed “on‐the‐fly” as the operator advanced the catheter toward each PV and was continuously available during lesion delivery.

2.5. Fluoroscopy PFA (n = 77): Procedural Specificities

To provide a comparative reference, we included a retrospective control group consisting of patients who underwent fluoroscopy‐guided PFA with no 3D mapping system. These procedures were retrospectively identified from institutional records and served as a benchmark for procedural performance.

All three groups (3D‐blinded, 3D‐EAM‐guided, and fluoroscopy) were mutually exclusive, with no overlap between patients.

2.6. Data Collection

The procedure time was defined from venous puncture to final catheter removal. The mean left atrial dwell time was defined from transseptal puncture to catheter withdrawal. The 3D mapping acquisition time was defined from catheter entry into the left atrium to completion of the anatomical map. To standardize the qualitative assessment of lesion coverage, each operator completed a post‐procedure evaluation using a predefined schematic template representing the PV antra. Each vein was divided into four segments, resulting in a total of 16 evaluable zones per patient (see Figure S1). The operator who performed the ablation was asked to answer targeted questions for each case: Do you consider the lesion set to be optimal for PVI? Are there any areas you would recommend additional lesion? If so, where? Are any applications excessively broad or extending outside the intended PV antrum? If so, where?

Operators indicated their responses on the segmented template, allowing for a semi‐quantitative visual analysis of lesion distribution.

2.7. Statistical Analysis

Descriptive statistics were used to summarize patient characteristics, procedural data, operator feedback, and lesion coverage patterns. Lesion coverage was analyzed semi‐quantitatively based on operator responses using the standardized PV segmentation template. Continuous variables were tested for normality using the Shapiro–Wilk test. Normally distributed variables were compared using Student's t‐test (two groups) or one‐way ANOVA (three groups). For non‐normally distributed variables, the Mann–Whitney U or Kruskal–Wallis test was applied. Categorical variables were compared using the chi‐square or Fisher's exact test. A p‐value <  0.05 was considered statistically significant.

To estimate the causal effect of treatment strategy (fluoroscopy‐only, 3D‐blinded, or real‐time 3D‐EAM guidance) on procedural efficiency, we performed inverse probability of treatment weighting (IPTW) based on a multinomial propensity score model [9]. The propensity score included baseline variables likely to influence treatment selection: age, sex, body mass index, hypertension, diabetes, prior stroke or transient ischemic attack, structural heart disease, atrial fibrillation type (paroxysmal or persistent), and preprocedural CT availability.

Standardized effect sizes for these covariates were reduced below the conventional threshold (< 0.25), indicating adequate balance between groups. Weighted linear regression was then used to assess the association between treatment group and procedural outcomes. Statistical analyses were performed using Stata version 15 (StataCorp, College Station, TX, USA).

3. Results

3.1. Baseline Characteristics

Baseline characteristics were comparable across groups (Table 1). The mean age was 68.0 ± 9.6 years, and the CHADS‐VASc score was 2.6 ± 1.5. Persistent atrial fibrillation was more frequent in the 3D‐EAM‐guided group than in the 3D‐blinded and fluoroscopy‐only groups (46.7%, 38.1%, and 23.7%, respectively, p = 0.030). Preprocedural CT imaging was available in 87.4% of procedures, without significant differences across groups (p = 0.131).

Table 1.

Patient characteristics.

	Fluoroscopy‐guided PFA (n = 77)	3D‐blinded PFA (n = 21)	3D mapping guided PFA (n = 45)	Total (n = 143)	p‐value
Age (years)	68.9 ± 8.3	64.9 ± 12.4	68.0 ± 10.1	68.0 ± 9.6	0.229
Female sex, % (n)	27 (35.1%)	5 (23.8%)	14 (31.1%)	46 (32.2%)	0.609
Body mass index (kg/m2)	27.7 ± 6.3	29.5 ± 5.4	28.6 ± 7.3	28.3 ± 6.5	0.513
Structural heart disease, % (n)	34 (44.2%)	8 (38.1%)	14 (31.1%)	56 (39.2%)	0.361
Persistent atrial fibrillation, % (n)	18 (23.7%)	8 (38.1%)	21 (46.7%)	47 (32.9%)	0.03
Post‐wall ablation, % (n)	10 (13.0%)	5 (23.8%)	4 (8.9%)	19 (13.3%)	0.249
Hypertension, % (n)	58 (75.3%)	5 (23.8%)	32 (71.1%)	95 (66.4%)	< 0.001
Diabetes, % (n)	14 (18.2%)	3 (14.3%)	3 (6.7%)	20 (14.0%)	0.209
Prior stroke, % (n)	8 (10.4%)	3 (14.3%)	9 (20.0%)	20 (14.0%)	0.336
CHADS‐VASc score, m±sd	2.8 ± 1.5	2.0 ± 1.4	2.5 ± 1.5	2.6 ± 1.5	0.101
Antiarrhythmic drugs, % (n)	64 (83.1%)	12 (57.1%)	36 (80.0%)	112 (78.3%)	0.036
Preprocedural CT scan, % (n)	64 (83.1%)	18 (85.7%)	43 (95.6%)	125 (87.4%)	0.131

3.2. 3D‐Blinded Group Procedural Characteristics

In the 3D‐blinded group, a total of 84 PVs were targeted with a mean total of 37.4 ± 9.8 applications. The mean pre‐ablation mapping time was 7.1 ± 3.2 min (Table 2). In 5 procedures (23.8%), at least one vein was not successfully isolated during the initial ablation sequence and required additional applications and operator notification. Three operators missed one vein each, and one operator missed two veins. These affected veins included two right inferior, two left superior, and one right superior.

Table 2.

Procedural characteristics.

	Fluoroscopy‐guided PFA (n = 77)	3D‐blinded PFA (n = 21)	3D‐EAM‐guided PFA (n = 45)	Total (n = 143)	p‐value
Procedure duration (min)	33.2 ± 8.2	31.9 ± 6.1	39.8 ± 9.6	35.1 ± 9.0	< 0.001
Catheter dwell time (min)	16.7 ± 4.3	27.0 ± 5.7	23.6 ± 7.2	20.5 ± 6.9	< 0.001
Mapping duration (min)	/	7.1 ± 3.2	/	7.1 ± 3.2	/
PVI applications, M ± SD	39.3 ± 10.5	38.4 ± 9.0	33.6 ± 7.8	37.4 ± 9.8	0.007
Posterior wall, M ± SD	1.6 ± 4.5	2.7 ± 5.3	6 ± 1.6	2 ± 4.7	0.144
Total number of applications, M ± SD	40.9 ± 11.5	41.1 ± 8.9	36.3 ± 14.4	40.8 ± 11.0	0.707
Fluoroscopy time (min)	8.1 ± 4.0	10.2 ± 2.7	8.5 ± 3.2	8.6 ± 3.6	0.059
Total Kerma dose (mGy·cm2)	434.2 ± 276.7	412.9 ± 255.6	457.3 ± 306.9	438.5 ± 282.3	0.83
Fluoroscopy dose (mGy)	39.4 ± 27.6	35.5 ± 23.6	45.8 ± 32.0	40.9 ± 28.5	0.345

In these five cases, all PVs exhibited atrial signals before ablation. Energy was initially delivered to an adjacent vein in error, most frequently to the right middle PV (2) (Figure 2). A preprocedural CT scan was available in four of these five cases.

Figure 2.

Example of a missed right inferior pulmonary vein (RIPV). Each panel shows fluoroscopic views alongside the corresponding 3D‐EAM catheter positions. Panels A and B illustrate applications delivered to the right superior and right intermediate pulmonary veins, the latter being mistaken for the RIPV. Panel C shows the actual application on the RIPV, which was hidden on fluoroscopy by the diaphragm. A preprocedural left atrial CT was not available for this patient. The catheter visible in the right atrium is a duodecapolar diagnostic catheter initially positioned along the tricuspid annulus for a planned CTI ablation. It migrated during the procedure, explaining its atypical position.

3.3. Post‐Procedural Case Review

Post‐procedure review of the 3D‐blinded cases with missed veins revealed a misinterpretation of catheter position during fluoroscopy‐guided cannulation, leading operators to believe a different vein had been accessed (see Figures 2, 3, 4, 5).

Figure 3.

Missed right inferior pulmonary vein (RIPV). Applications were delivered to the right intermediate pulmonary vein. The RIPV, located more posteriorly, was not catheterized. (A) Catheterization of the right intermediate pulmonary vein and (B) catheterization of the RSPV. (C) Posterior view of the 3D left atrial map showing missing applications in the RIPV. (D) Catheterization of the RIPV.

Figure 4.

Missed right superior pulmonary vein (RSPV). The right inferior pulmonary vein was targeted twice. (A) Inferior branch of the RIPV. (B) Superior branch of the RIPV. (C) RSPV identified after PVI completion.

Figure 5.

Each panel shows the fluoroscopic view and the corresponding 3D mapping view of the pentaspline catheter during left pulmonary vein isolation. Catheterization of the inferior left pulmonary vein (LIPV, A). A typical example of catheterization of the left superior pulmonary vein (LSPV) in both its inferior (B) and superior (C) branches demonstrating the different guide trajectory mimicking LIPV catheterization. In this case, LSPV isolation was performed using the inferior LSPV branch. Catheterization of the superior branch of the LSPV revealed incomplete antral isolation of the left superior part of the pulmonary vein, which benefited from additional applications.

Seventy‐seven of 84 PVs (91.7%) were considered to have satisfactory lesion placement and coverage. The operators proposed a modified ablation strategy in 10 out of 21 procedures (47.6%). Among these, 6 cases (28.6%) involved suggestions for additional applications: 3 PV would have benefited from more antral positioning, and 3 from overlapping lesions to improve continuity. In 4 procedures (19.0%), operators reported that some applications could have been avoided specifically on the posterior wall in 4 cases and near the mitral isthmus in 1 case (Table 3 and Figure 6).

Table 3.

Post‐procedure review in 3D‐blinded group.

	n (%)
Number of veins targeted	84 (100%)
Missed PVI in first attempt	5 (5.9%)
Optimal lesion placement	77 (91.5%)
Procedure with modified application	10/21 (47.6%)
PV needing more antral coverage	3 (14.3%)
Requiring PVs overlapping applications	3 (14.3%)
Unwanted extra PV applications	4 (19.0%)

Figure 6.

3D electroanatomical maps of the left atrium with visual representation of PFA lesions. Top panel: PVI in a patient with paroxysmal atrial fibrillation. Retrospective review indicated that roof lesions may have been unnecessary. Bottom panel: A posterior wall application appears redundant, while additional lesions on the left inferior pulmonary vein would have been desirable.

3.4. Procedural Characteristics After 3D‐EAM Implementation

The 3D‐EAM‐guided group achieved complete initial isolation of all targeted PVs. The mean procedure duration was significantly longer in the 3D‐EAM‐guided group (39.8 ± 9.6 min) compared to the 3D‐blinded group (31.9 ± 6.1 min) and the fluoroscopy group (33.2 ± 8.2 min) (p < 0.001). The catheter left atrial dwell time was significantly higher in the 3D‐blinded and 3D‐EAM‐guided group (27.0 ± 5.7 and 23.6 ± 7.2 min) compared to fluoroscopy‐guided, and 16.7 ± 4.3 min (p < 0.001). No post‐procedural reviews in the 3D‐EAM‐guided group resulted in modifications of the ablation strategy.

The mean number of PVI applications was lower in the 3D‐EAM‐guided group (33.6 ± 7.8), compared to the 3D‐blinded group and to the fluoroscopy group (38.4 ± 9.0 and 39.3 ± 10.5, p = 0.007). In the weighted regression model, 3D‐EAM‐guided procedures required significantly fewer PVI applications compared to fluoroscopy‐only (adjusted mean difference –6.3 applications, 95% CI [–9.8, –2.7], p < 0.001), whereas the 3D‐blinded group did not differ (–2.2 applications, 95% CI [–6.3, 1.9], p = 0.29). Procedural duration was significantly longer with in 3D‐EAM‐guided PFA (+8.2 min, 95% CI [3.8–12.5], p < 0.001), while the 3D‐blinded group showed no significant difference. Left atrial dwell time increased both in 3D‐blinded (+11.0 min, 95% CI [8.6–13.4], p < 0.001) and 3D‐EAM‐guided PFA (+7.9 min, 95% CI [4.8–10.9], p < 0.001) compared with fluoroscopy‐only procedures.

No major complications were reported. One pericardial effusion, related to transseptal puncture, occurred in the 3D‐EAM‐guided group and was managed conservatively.

4. Discussion

The present proof‐of‐concept study describes the potential value of 3D anatomical mapping in the PVI procedure with PFA. Despite operator experience with fluoroscopy‐guided workflows, 3D anatomical mapping revealed mismatches between perceived and actual catheter positioning. In 23.8% of blinded procedures, at least one PV was not identified using fluoroscopy, despite experienced operators and CT review. During fluoroscopy‐guided PV catheterization, anatomical misperception may go unnoticed. In contrast, real‐time 3D‐EAM guidance identified all missed veins.

Recent international consensus confirms that fluoroscopy remains the primary modality for PFA worldwide and that the selective use of adjunctive tools may enhance anatomical accuracy and procedural safety [8, 10]. In this context, detailed anatomical knowledge is central to successful PVI. Unlike cryoballoon ablation, where venography provides immediate anatomical feedback, or radiofrequency workflows where 3D mapping is standard, the pentaspline PFA catheter is typically guided by fluoroscopy alone with substantial heterogeneity regarding the use of adjunctive imaging such as CT‐fusion or 3D mapping [8, 11, 12, 13, 14]. As a result, anatomical cues may be misleading, particularly in posterior and inferior veins when the guidewire followed an unusual trajectory or when catheter shaft movements mimicked a typical positioning (see Figures 2, 3, 4). Using fluoroscopy only, the effectiveness of each application is assessed almost exclusively by local electrogram recordings. These factors, together with the lesion geometry and energy delivery pattern of PFA, may lead to overlapping applications and partial electrical silencing of adjacent veins masking reversible or incomplete isolation (Central_Illustration 1). Similar findings were reported with the fourth‐generation cryoballoon, where high‐density mapping identified residual conduction gaps not detected by conventional tools [15].

Central_Illustration 1.

Impact of real‐time 3D electroanatomical mapping during pulsed field ablation. In a three‐phase comparison (fluoroscopy‐only, 3D‐blinded, and real‐time 3D‐EAM), 23.8% of blinded procedures missed at least one pulmonary vein. Real‐time 3D mapping eliminated missed veins and reduced PVI applications. 3D‐EAM, three‐dimensional electroanatomical mapping; CT, computed tomography; LA, left atrium; PV, pulmonary vein.

When combined with fluoroscopy, preprocedural cardiac CT provides a detailed 3D understanding of the left atrium and is widely used for procedural planning. It can be displayed as a static anatomical reference during the procedure, although it does not provide real‐time spatial feedback except when fused with fluoroscopy. However, CT–fluoroscopy fusion tools are not widely available, and manual registration based on anatomical landmarks may limit the spatial accuracy of the fusion [10]. Alternative intraprocedural imaging strategies, such as rotational angiography or intracardiac echocardiography, can also provide anatomical guidance but are limited by radiation, contrast exposure, or availability [16, 17].

Over the past decades, electroanatomical mapping systems have become a central component of catheter ablation workflows. They allow the creation of a standalone anatomical map, provide precise localization of applications and visual confirmation of lesion continuity, both of which are essential to ensure durable PVI. They enable fusion of preprocedural CT datasets with the 3D map, potentially further improving PV identification and isolation. More precisely targeted applications around the PV may have safety and efficacy implications with large‐footprint PFA catheter. They may help preserve extra‐venous structures, such as the roof and mitral isthmus, from unnecessary spillover lesions and reduce the number of applications. Although long‐term durability could not be assessed in the present study, the improved precision of PVI and the more homogeneous distribution of applications observed with 3D‐EAM may theoretically support better lesion durability, as incomplete antral coverage and spatial dispersion of applications have been associated with reconnection [2, 18].

In the redo study, the pentaspline PFA catheter achieved durable PVI in ≈87% of PVs [19]. Likewise, MANIFEST‐REDO and the EU‐PORIA registry reported lower durability rates, considering that apparently complete acute PVI can conceal reconnections at follow‐up [18, 20]. These registries do not evaluate how fluoroscopic misperception may contribute to incomplete or misplaced lesions. However, our study does not determine whether such misperception is systematically shared by all experienced operators relying on optimized fluoroscopic workflows and multiple projections. It is nevertheless very likely that, as experience accumulates, fluoroscopy alone achieves a high probability of successfully targeting all PVs.

Electroanatomical mapping usually shortens fluoroscopy time; however, this benefit was not evident in our study. Recent technical reports confirm that additional mapping significantly increases procedural and left atrial dwell times without reducing recurrence at 1 year [7]. Zei et al. reported significantly shorter overall procedure times when low‐fluoroscopy operators used an integrated mapping workflow [6]. In the 3D‐blinded group, the mean added mapping time of the left atria was 7 ± 3 min, representing an acceptable extension while the operators remained fully reliant on fluoroscopy. In the routine use of 3D‐EAM, procedure and mapping times were longer. The learning curve associated with its implementation likely led to concurrent fluoroscopic use, limiting the reduction in exposure. Similar observations were reported by Badertscher et al., where the introduction of 3D‐EAM in PFA procedures resulted in longer procedural times during the initial adoption phase, attributed to operator familiarization with the system [7]. As operator experience grows, these differences can reasonably be expected to decrease and suggest that once integrated, 3D‐EAM guidance may even streamline PFA workflows. A more limited mapping approach focused solely on the PVs could further reduce the time required and maintain the benefit of the shorter PVI duration with PFA.

Following this experience, our team derived three practical lessons to minimize the risk of missed vein during fluoroscopy‐guided PFA: (1) meticulous attention to the catheterization of veins, systematically exploring all quadrants of the left atrium; (2) the use of complementary anatomical imaging whenever available (CT, TEE), although these alone are not always sufficient; and (3) awareness that inferior or superior veins can mimic the catheter trajectory typically seen in upper lobes, potentially misleading even experienced operators.

This study has limitations. It was conducted in a single center with a moderate sample size, and therefore, the results should be interpreted as proof‐of‐concept rather than a definitive demonstration. The most original component, the blinded phase with pre‐acquired 3D maps withheld from the operator, included only 21 patients, which prevents robust stratification of predictors of fluoroscopic misperception, such as uncommon PV anatomies or differences in operator experience. Nevertheless, this design constitutes a methodological strength, since it isolates the contribution of 3D anatomical mapping to PV targeting. Second, the historical fluoroscopy‐only cohort, although useful for contextual comparison, adds limited methodological weight due to its retrospective design. Third, CT–fluoroscopy fusion was not performed, as this technique is not a standard practice in our center and is inconsistently adopted in international practice. Finally, post‐procedural operator assessment was partly subjective, although reviewed independently.

The present results are specific to the Faraview (Opal, Boston Scientific) mapping environment integrated with the pentaspline PFA system. Other mapping platforms and PFA systems differ in catheter geometry, reconstruction algorithms, and workflow design; similar studies using these alternative technologies may yield different findings.

Future studies are required to confirm if integration of 3D anatomical mapping into PFA workflows improves clinical outcomes, particularly in complex anatomies or early‐career operators, and to determine if selective use of 3D mapping could enhance both safety and efficiency with favorable health‐economic implications.

5. Conclusion

The implementation of a 3D electroanatomical mapping system revealed the challenges of accurately identifying PVs using fluoroscopy alone. As PFA expands beyond PVI to more complex ablation strategies, the role of anatomical guidance tools such as 3D‐EAM will become increasingly important. Its routine use must be weighed against cost and clinical benefit; 3D‐EAM may enhance procedural accuracy. Further studies are warranted to evaluate its long‐term clinical impact.

Funding

The authors received no specific funding for this work.

Ethics Statement

The study was conducted in accordance with the principles of the Declaration of Helsinki. The research protocol was reviewed and approved by the Institutional Review Board of Clermont‐Ferrand University Hospital (Approval ID: 2025‐CF465).

Consent

All patients provided written informed consent for the procedure and for the anonymized use of their data for research and publication purposes.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information.

Data Availability Statement

De‐identified participant data, analytic code, and study materials are available from the corresponding author upon reasonable request.