Pulsed Field Ablation of Atrial Fibrillation: A Comprehensive Review

Abstract

Pulsed-field ablation (PFA) has emerged as a promising nonthermal ablation alternative for treating atrial fibrillation (AF). By delivering ultra-rapid high-energy electrical pulses, PFA induces irreversible electroporation, selectively targeting myocardial tissue while sparing adjacent structures from thermal or other damage. This article provides a comprehensive review of multiple pre-clinical studies, clinical studies, and clinical trials evaluating the safety, efficacy, and long-term outcomes of PFA in various settings and patient populations. Overall, the reviewed evidence highlights PFA's potential as a revolutionary ablation strategy for AF treatment. Offering comparable procedural efficacy to conventional ablation methods, PFA distinguishes itself with shorter procedure times and reduced risks of complications such as phrenic nerve palsy and potential esophageal injury. While further research is warranted to establish long-term efficacy, PFA's distinct advantages and evolving clinical evidence suggest a promising future for this novel nonthermal ablation approach. As PFA continues to advance, it has the potential to transform AF ablation procedures, providing a safer alternative for patients with atrial fibrillation.

Keywords: atrial fibrillation; catheter ablation; pulsed-field ablation.

Fig. 1.

Pulmonary vein and posterior wall isolation performed with PFA. Electroanatomic mapping of the left- and right-sided pulmonary veins as well as the posterior wall of the left atrium before and 3 months after pulmonary vein and posterior wall isolation with the Farapulse PFA System. Courtesy of Dr. Jorge E Romero. PFA, pulsed-field ablation; PVI, pulmonary vein isolation; PWI, posterior wall isolation.

Fig. 2.

Pulsed-field ablation waveform parameters. Waveform modifiable parameters determine the target tissue, as well as the lesion’s durability and extension. Reprinted from JACC: EP, 33(7), Romero et al., Pulsed-field ablation: What are the unknowns and when will they cease to concern us?, with permission from Elsevier [21].

Fig. 3.

Irreversible electroporation (IRE). Illustration of the IRE process, as part of which exposure to a predetermined energy field results in increased cell membrane permeability leading to cardiac death. Reprinted from JACC: EP, 32(6), Romero et al., Pulsed field catheter ablation in atrial fibrillation, with permission from Elsevier [41].

Fig. 4.

Pulsed-field ablation (PFA) catheter parameters. Catheter shape, electrode disposition, and mechanism of deployment and navigation determine the target tissue, as well as the lesion’s durability and extension. (A) PFA Farawave catheter (Farapulse, Boston Scientific). (B) PFA, Pulmonary vein Ablation Catheter GOLD (PVAC GOLD; Medtronic, Inc.). (C) PFA circular contractable Varipulse ablation catheter (Biosense Webster, Inc.). Reprinted from JACC: EP, 33(7), Romero et al., Pulsed-field ablation: What are the unknowns and when will they cease to concern us?, with permission from Elsevier [21].

Fig. 5.

Radiofrequency ablation (RFA) vs. pulsed-field ablation (PFA) lesion characteristics. PFA produces more predictable and homogeneous lesions in the myocardium when compared with RFA, particularly on uneven surfaces. (A,B) The growth of radiofrequency (RF) lesions triggers an inflammatory process, which limits its capacity to deliver a successful transmural lesion. (C,D) PFA lesions are consistently more homogeneous than RFA lesions. Reprinted from JACC: EP, 32(6), Romero et al., Pulsed field catheter ablation in atrial fibrillation, with permission from Elsevier [41].

Fig. 6.

Pulsed-field ablation (PFA) selectivity. PFA offers the potential to selectively target myocardial tissue while avoiding detrimental effects on nearby structures such as red blood cells, the phrenic nerve, the esophagus, or coronary vessels. Reprinted from JACC: EP, 33(7), Romero et al., Pulsed-field ablation: What are the unknowns and when will they cease to concern us?, with permission from Elsevier [21].