Catheter ablation using pulsed-field energy: Advantages and limitations compared with conventional energy

Atrial fibrillation (AF) poses significant risks of heart failure and stroke, emphasizing effective treatment. Catheter ablation using thermal energy sources, such as radiofrequency or cryoballoon ablation, has shown greater success in maintaining sinus rhythm compared with drug therapy. However, thermal ablation (TA) is associated with serious complications, such as atrial-esophageal fistula, phrenic nerve palsy, and pulmonary vein stenosis. Pulsed-field ablation (PFA) is an emerging ablation energy source that uses electroporation to selectively target cardiac tissue while sparing adjacent structures such as nerves and blood vessels. Two randomized controlled trials have demonstrated that PFA is comparable to TA in both efficacy and safety at a 1-year follow-up and had shorter procedure times. A review of six meta-analyses consistently showed shorter procedural times for PFA across all studies. Additionally, three out of the four recent studies with large samples reported lower recurrence rates with PFA. Regarding complication rates, four out of four studies showed lower incidences of phrenic nerve injury with PFA, and two out of three studies reported lower rates of esophageal injury with PFA. However, four out of four studies indicated higher incidences of cardiac tamponade with PFA, highlighting the need for caution among early-career operators. Furthermore, careful monitoring is required considering the possible unforeseen complications specific to PFA and the lack of long-term follow-up data. Despite these concerns, PFA shows promise as a safer, more effective, and efficient alternative to TA for AF, particularly as operator experience and device technology continue to advance.