Advent of Pulsed Field Ablation for Atrial Fibrillation: State-of-the-Art Review

Pulsed field ablation (PFA) is a novel ablation technique for atrial fibrillation (AF). Indeed, PFA utilizes cell electroporation and exhibits selectivity for myocardial tissue, depending on the method used to deliver the pulsed electric field, potentially sparing surrounding non-cardiac structures. Recent clinical trials have demonstrated the non-inferiority of PFA compared with conventional thermal ablation for arrhythmia recurrence, including radiofrequency and cryoballoon ablation. Currently, large registry data present an acceptable safety profile. However, PFA is not without risk, and some unique, albeit infrequent complications have been recognized with this ablation modality, including stroke, coronary artery spasm, and intravascular hemolysis. Thus, given the associated safety, efficacy, and improved procedural workflow of this technique, the advent of PFA will likely lower the threshold for patient selection for AF ablation, particularly owing to the growing burden of AF in our community. This review provides an overview of the biophysics of PFA, various catheter designs, clinical trial and registry data, potential complications associated with PFA, and future directions in this promising area of AF management.