Complications of pulsed-field ablation for atrial fibrillation: a narrative structured review

Pulsed-field ablation (PFA) has been adopted at remarkable speed as a non-thermal approach for pulmonary vein isolation in atrial fibrillation (AF). Its mechanism-irreversible electroporation-preferentially injures cardiomyocytes while theoretically sparing adjacent heat-sensitive structures. Landmark randomised trial data (ADVENT) and large prospective registries (MANIFEST-17K; MANIFEST-PF) confirm that PFA is non-inferior to conventional thermal ablation for arrhythmia freedom and carries an overall favourable safety profile, with particularly low rates of atrooesophageal fistula and pulmonary vein stenosis. Nonetheless, substituting electrical for thermal energy introduces a qualitatively distinct injury spectrum. Intravascular haemolysis, acute kidney injury, transient coronary vasospasm, phrenic nerve stimulation, silent cerebral emboli, and-importantly-the risk of ventricular fibrillation during unsynchronised pulse delivery have each been documented across prospective cohorts and multicentre registries. This review provides a narrative structured synthesis of mechanistic and clinical evidence for each PFA-associated complication, proposes a three-tier classification (PFA-specific, PFA-enriched, and general ablation-related), and outlines practical risk-mitigation strategies. Recognition that "non-thermal" does not equate to "risk-free" is essential as PFA transitions to standard of care.