Pulsed field ablation for atrial fibrillation induces intravascular hemolysis, with procedures exceeding 90 to 100 applications significantly increasing the risk of acute kidney injury.
Hemolysis is a frequent consequence of pulsed field ablation for atrial fibrillation that can lead to acute kidney injury, highlighting the need for preventive strategies like preprocedural hydration and limiting the number of applications.
Pulsed field ablation (PFA) has emerged as a promising non-thermal energy source for treating atrial fibrillation (AF), demonstrating comparable efficacy to traditional thermal ablation techniques while offering an improved safety profile. However, recent evidence suggests that PFA may be associated with intravascular hemolysis, a complication that can potentially lead to acute kidney injury (AKI). This review aims to provide a comprehensive overview of the mechanisms of hemolysis associated with PFA and to summarize current strategies to mitigate the risk of AKI. The delivery of high-voltage electrical pulses during PFA can induce red blood cell lysis, resulting in elevated circulating free hemoglobin. The extent of hemolysis has been shown to correlate with several procedural variables, including peak output voltage, catheter-tissue contact quality, and, particularly, the number of energy applications delivered. Recent studies have highlighted that adequate preprocedural hydration may effectively reduce the incidence of AKI by promoting renal clearance of hemolytic products. Although hemolysis appears to be an unavoidable effect of pulsed field ablation, the clinical consequences associated with hemolysis, particularly AKI, can be significantly reduced with preventive measures.
Cersosimo et al. (2026) conducted a review in Atrial Fibrillation. Pulsed Field Ablation (PFA) vs. Thermal ablation (Radiofrequency or Cryoablation) was evaluated on Intravascular hemolysis and Acute Kidney Injury (AKI). Pulsed field ablation for atrial fibrillation induces intravascular hemolysis, with procedures exceeding 90 to 100 applications significantly increasing the risk of acute kidney injury.