Pulsed-Field Ablation: The ‘perfect’ energy source?

Take Home Messages
  • Pulmonary vein isolation (PVI) is the cornerstone of AF ablation and the most common ablation procedure.
  • Long-term success of single-procedure PVI with thermal energy sources (radiofrequency and cryoablation) remains suboptimal.
  • Pulsed-field ablation is a novel nonthermal energy source which causes irreversible tissue injury with high sensitivity for cardiomyocyte with the potential to improve procedural efficacy and safety.
  • Initial clinical experience showed promising results, but further studies are needed to establish safety, particularly the risk of asymptomatic cerebral embolism, and long-term efficacy.

The main aim of ablation is to electrically isolate the arrhythmogenic area by creating durable full-thickness (transmural) damage to the target tissue whilst sparing adjacent structures. Traditionally, thermal injury sources have been used. However, as thermal ablation causes indiscriminate tissue injury, a trade-off exists between safety and efficacy ― transmurality may only be achieved with higher energies and/or longer durations at the expense of an increased likelihood of inadvertent collateral injury. Pulsed-field ablation (PFA) promises to revolutionise the field of catheter ablation by delivering non-thermal ultrafast, irreversible tissue injury with high sensitivity for cardiomyocytes and, thus, improve both safety and efficacy with shorter procedural times.

The electrophysiology community has welcomed this new technology with many postulating that PFA is a ‘game changer’ and ‘the future’ of arrhythmia management. Similar excitement is shared by the industry with several companies developing proprietary PFA delivery systems and sponsoring research studies. Preclinical data has been encouraging but does the initial clinical experience live up to this hype?