Pulsed field ablation: a new standard for single-shot atrial fibrillation ablation

Introduction Pulsed field ablation (PFA) induces cell death through electroporation, offering a potentially safer and more effective method for atrial fibrillation (AF) ablation. Purpose To compare the acute and long-term efficacy, safety, and procedural duration of PFA and cryoablation (CA) for pulmonary vein isolation (PVI). Methods This single-center, prospective study included AF patients (pts) undergoing PVI with either PFA (Farapulse system) or CA from January 2023 to November 2024. Ablation included cavotricuspid isthmus (CTI) ablation for pts with concomitant atrial flutter (AFL). Groups were matched using propensity scores based on AF type and CHA2DS2-VASc scores. Acute success was defined as complete PVI. Safety was assessed by major/minor complications, and procedural duration was defined as the total skin-to-skin time. Kaplan-Meier survival analysis was used to compare the long-term efficacy, defined as freedom from AF, or atrial tachycardia post a 90-day blanking period. Results Of 315 pts undergoing PVI, 204 were matched (1:1): 64% male, 66±13 years, CHA2DS2-VASc 2.4±1.3, with paroxysmal (69%), short-duration (14%), or long-standing persistent AF (15%). Acute success (PFA: 99% vs. CA: 96%), major (PFA: 2% vs. CA: 1%) and minor complications (PFA: 1% vs. 5%) showed no significant differences (Table 1). Procedure time, which included CTI ablation in 20%, was shorter with PFA (55±25 vs. 84±28 min, p<0.001) with similar fluoroscopy times (Table 1). One PFA pt died from femoral hemorrhage within 30 days. Over a 469±19 days median follow-up, long-term efficacy showed no significant difference (PFA: 72% vs. CA: 66%) (Table 2). Conclusion PFA is an innovative technology for rapid PVI with comparable safety and efficacy, establishing it as the preferred single-shot AF ablation technique.