Evolution of the complication profile of AF ablation in the pulsed field era

Pulsed field ablation (PFA) has revolutionized atrial fibrillation (AF) treatment by leveraging non-thermal irreversible electroporation and relative myocardial tissue selectivity. While early clinical data and large registries demonstrated near-elimination of conventional thermal injuries-including atrioesophageal fistula, persistent phrenic nerve injury, and pulmonary vein stenosis-the ongoing accumulation of real-world experience has revealed a spectrum of energy-specific adverse events (AEs), some of which are relatively unique to PFA, such as coronary artery spasm and hemolysis. Multicenter registries such as MANIFEST-17 K and MANIFEST-US confirm a low overall major AE rate (<1%), highlighting the safety of PFA. However, some of these distinct AEs continue to be reported at clinically significant frequencies. Furthermore, recent reports have raised concerns regarding rare but life-threatening delayed arrhythmic events possibly related to coronary spasm. These findings suggest that the safety profile of PFA for AF has changed to involve different events rather than an overall improvement. Traditional AEs associated with venous access and left atrial instrumentation remain. This review summarizes the evolving landscape of AEs seen with PFA for AF, focusing on energy-specific AEs, their underlying mechanisms, and the clinical implications for procedural optimization and postprocedural management.