Pulsed Field Ablation in Patients With Cardiac Implantable Electric Devices: Vigilance Is Warranted

Pulsed field ablation (PFA) for the treatment of atrial fibrillation offers potential safety benefits compared to thermal ablation modalities. However, the high voltage electric pulses required to irreversibly electroporate myocardial cells present a unique clinical challenge in regard to patients with cardiac implantable electronic devices (CIEDs). The strong electric fields of PFA can induce voltages and currents in CIED leads, which may result in electromagnetic interference (EMI) or even permanent damage to the device itself, requiring reset or replacement. Limited evidence exists on PFA procedures in patients with CIEDs. Historically, clinical trials have excluded patients with CIEDs, which leaves evidence from real-world clinical practice to fill this critical evidence gap. This review describes the potential hazards when performing PFA in patients with CIEDs, current real-world evidence in such patients, and recommended workflows to mitigate risk and prioritize patient safety.