Safety considerations and clinical monitoring during pulsed field ablation

Pulsed field ablation (PFA) has emerged as a transformative technology in cardiac electrophysiology, offering a potentially superior safety profile compared with thermal ablation due to its non-thermal mechanism of irreversible electroporation. Clinical experience confirms a substantial reduction in traditional complications such as pulmonary vein stenosis, atrio-oesophageal fistula, and permanent phrenic nerve injury, though PFA introduces a distinct spectrum of physiologic effects requiring consideration. Coronary vasospasm is the most characteristic phenomenon, ranging from transient, subclinical constriction to rare ischaemic or arrhythmic events; mitigation relies on coronary anatomical awareness, optimized lesion placement, and prophylactic vasodilators. Haemolysis, caused by red blood cell electroporation, varies with catheter design and pulse burden and is typically mild, though high exposure and inadequate hydration may rarely lead to acute kidney injury. Silent cerebral lesions could result from procedural and/or energy-related factors, including gas formation, air ingress, catheter manipulation, and anticoagulation management, with uncertain long-term clinical impact but opportunities for technique-driven reduction. Interactions between PFA and cardiac implantable electronic devices are system- and context-dependent, with monopolar configurations and catheter-lead proximity influencing the risk of transient interference and rare permanent damage.