Analysis of pulsed field ablation using focal contact force-sensing catheters for treatment of atrial fibrillation: acute and 90-day invasive remapping results

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com We congratulate Anić et al. on their analysis of pulsed field ablation (PFA) using focal contact force-sensing catheters for treatment of atrial fibrillation (AF): acute and 90-day invasive remapping results. Their results are particularly pertinent as they highlight the safety and efficacy of solid tip focal PFA as a treatment for AF, which was not done previously, indicating this form of therapy could play an important role in the future of treating AF. One important factor in determining the viability of this treatment is the number of serious side effects seen in patients. The authors recorded four serious adverse events of interest (4.9%), higher than a similar study by Reddy et al., which recently compared PFA and conventional thermal ablation interventions for AF (2.1%). We note that this could be due to the limited sample size, as Reddy et al.’s lower adverse event rate is corroborated by Shtembari et al.’s systematic review into the safety and efficacy of PFA in AF. Also worthy of note is that the patients were only followed up for 90 days after the procedure, which may not be adequate to assess long-term side effects. This is particularly important as those undergoing ablation procedures for AF are often relatively young, with Kneeland and Fang reporting a mean age of 66. Furthermore, incidences of stroke and major bleeding have been shown to rise from 5 years post-ablation. We therefore suggest a long-term study should be conducted in order to further investigate the safety of PFA. Whilst Anić et al.’s 89% per-pulmonary vein (PV) chronic durability rate is promising, we note that this method may not provide enough information to assess the chronic durability of pulmonary vein isolation. As the authors note, 1 year freedom from atrial arrythmias is the benchmark through which this ablation strategy should be tested. We suggest a long-term study similar to Ouyang et al.’s, which observed patients for 5 years after their ablation procedures. Ouyang et al. highlighted the need for additional procedures following the blanking period, which would result in increased success rate. This would provide a more comprehensive overview into the long-term efficacy of PFA. Whilst Anić et al. provide strong evidence for the use of PFA, the results may not be generalizable. The lack of detailed patient demographics including ethnicity makes applicability to broader patient populations challenging. Moreover, a small sample size may not generate results with the statistical power necessary to effect change in the population. Therefore, further multi-national studies should be conducted in order to address this issue. In summary, this study by Anić et al. demonstrates great insight and potential for PFA therapy in treating AF. Their findings serve as a solid foundation that could be the cornerstone of future therapies for AF. However, as mentioned, we believe these findings can be furthered by broadening the study’s sample size, investigating the longer term adverse effects of PFA and comparing outcomes against established therapies. Nonetheless, we look forward to future studies examining this innovative therapy.