A prospective study found pulsed field ablation to be effective with minimal safety concerns.

Pulsed field ablation (PFA) involves giving pulses of energy that destroy cardiac myocytes preferentially and quickly through a mechanism called electroporation (i.e. punching tiny holes in cells that instantly cause cell death). PFA is one of the most exciting fields in cardiac electrophysiology because it holds the promise to make ablation of atrial fibrillation (AF) quicker, safer and more effective. In the manufacturer-supported Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF (PULSED AF) Trial (NCT04198701), 150 patients with paroxysmal AF and 150 with persistent AF underwent PFA ablation and were followed prospectively for one year, including sequential electrocardiography and Holter monitoring.

The primary efficacy endpoint – freedom from AF, procedural failure or antiarrhythmic drug escalation – was achieved at one year by 66.2% of the paroxysmal AF group and 55.1% of the persistent AF group; 8% of the paroxysmal group and 9% of the persistent group had a repeat ablation. Acute complications (a cerebrovascular accident and pericardial effusion requiring drainage) occurred in one patient in each group. During follow up, one patient in the paroxysmal group died of liver failure, and one patient in the persistent group died of a cardiac arrest two weeks after dofetilide was initiated.

Comment: PFA is the most discussed ablation technique in years. It is already in widespread use in Europe, where well over 10,000 patients have received it. It has not been compared with cryoablation or radiofrequency ablation in a randomised trial; such a study would be welcomed, but would probably have to include many patients, as the effectiveness of the two approaches appears to be similar with the safety profile possibly better for PFA. Still, given the extensive use in Europe, many in the USA are eager to get their hands on this catheter.

Mark S. Link, MD
Professor of Medicine and Director, Cardiac Electrophysiology, UT Southwestern Medical Center, Dallas, USA.

Verma A, et al. Pulsed field ablation for the treatment of atrial fibrillation: PULSED AF pivotal trial. Circulation 2023 Mar 6; e-pub (https://doi.org/10.1161/CIRCULATION AHA.123.063988).

This summary is taken from the following Journal Watch title: Cardiology