Methods and techniques to optimize energy delivery using the circular array pulsed field ablation catheter

Pulsed field ablation (PFA) is a novel method of cardiac ablation in which electrical fields are used to create microscopic pores in the cardiomyocyte cell membrane, resulting in cell death. Unlike traditional thermal radiofrequency and cryoablation technologies, PFA is cardiomyocyte preferential, reducing the risk of collateral damage to the esophagus and phrenic nerve. However, achieving durable lesions with PFA is dependent on the proximity to the tissue and presently approved systems do not provide contact force sensing. The PulseSelect PFA system is the first Food and Drug Administration-approved/CE-marked/Pharmaceuticals and Medical Devices Agency-approved system for PFA of atrial fibrillation; however, there is no consensus on workflow and best practices. We present here real-world experience from our centers in the United States, Europe, and Japan, and propose techniques and methods for incorporating fluoroscopy, electroanatomic mapping, and intracardiac echocardiography to assure optimal lesion delivery and predictability.