Atrial fibrillation ablation energy source transition and adjunctive lesion set utilization after commercial release of pulse field ablation

BACKGROUND Trial data has demonstrated the safety and effectiveness of pulsed field ablation(PFA) for atrial fibrillation(AF) is non-inferior to radiofrequency(RF) and cryoballoon(CB); comparative real-world data on energy source utilization remains limited. OBJECTIVE To compare utilization, baseline characteristics, procedural characteristics, and acute safety of AF ablation with PFA, RF, CB, and combinations of these energies, performed between January 2024 and March 2025. METHODS We performed multivariable logistic regression models to compare risk of any adverse event and major adverse events (MAEs) of AF ablations reported to the National Cardiovascular Data Registry AFib Ablation Registry . RESULTS At 158 US sites the use of PFA and PFA+RF increased from 0% to 60% and 15%, respectively, while utilization of RF, CB, and RF+CB decreased from 72%, 16%, and 12% to 22%, 2%, and 1%, respectively. The median site monthly volume of AF ablations increased by nearly 50%. Baseline characteristics were similar across energy sources. PFA was associated with shorter procedures and marked changes in the adjunctive lesion utilization, with an increase in left atrial roof/floor/posterior wall ablation and decrease in cavotricuspid isthmus ablation. There were no differences in the adjusted risk of any adverse event or MAEs. CONCLUSIONS Over the first 15 month since the US commercial release of PFA, there was an almost complete transition from RF, CB, and RF+CB to PFA and PFA+RF. This was a associated with a decrease in procedure times and a 50% increase in procedure volumes. Baseline characteristics and acute procedural safety were similar across energy sources.