Table 1 Summary the foundational practical aspects for CBA and PFA

Patient preparation

Pre-procedural transesophageal echocardiography to exclude thrombi, and for pulmonary vein anatomy screening

Sedation

Typically under conscious sedation carefully using midazolam, propofol, fentanyl boluses and propofol infusion

Esophageal temperature monitoring

For patients undergoing CBA, using esophageal temperature probe for temperature monitoring (freeze termination at cut-off point < 15 °C)

Groin accesses

*Two groin-site punctures for venous accesses, one for positioning diagnostic catheter in coronary sinus (CS), one for single transseptal puncture

*Femoral vein access with relatively shallow angle of puncture due to the size of the steerable sheath (FlexCath steerable sheath for CBA, Medtronic, ID/OD: 12/15 Fr; FARADRIVE steerable sheath for PFA, FARAPULSE, Boston Scientific, ID/OD: 13/16.8 Fr), and for smooth delivery of the ablation catheter

Anticoagulation

For the ablation procedure, targeting ACT between 300 and 400 s. Patients taking warfarin should be judged by the therapeutic international normalized ratio level. Patients taking NOACs, 12 to 24 h of freedom from NOACs

Transseptal puncture

A central transseptal puncture may be advised for sheath/catheter manipulation and readily accessing both the lateral and the septal PVs. For difficult transseptal cases, assistance using TEE should be considered

Anatomy assessment

Selective angiography for pulmonary veins for baseline anatomic assessment (e.g. PV, PV ostia, PV-atrium)

Sheath preparation and exchange

*Adequate flushing the steerable FlexCath or FARADRIVE sheath and air clearing

*Manipulation the steerable sheaths or CB/PFA catheters should be leaded and protected by either soft-tip “J” shape guide wire or soft-tip mapping catheter

CBA basic maneuvers

*Ablation in clockwise fashion (LSPV, LIPV, RIPV, RSPV)

*Basic balloon maneuvers: 1. Direct approach (LSPV, RSPV, RIPV), 2. hockey-stick approach (LIPV and RIPV), 3. Pull-down maneuver (LIPV and RIPV, in combination with direct approach or hockey-stick approach), 4. Pull away (RSPV, pull away the distance between CB and phrenic nerve)

PFA basic maneuvers

*Ablation in clockwise fashion (LSPV, LIPV, RIPV, RSPV)

*Basic balloon maneuvers: “8 applications ablation protocol” for each PV using different configurations, i.e. 2 in basket configuration —> rotation (for lesion overlapping) —> another 2 in basket configuration —> 2 in flower configuration (for PV antral lesion) —> rotation —> another 2 in flower configuration