Pulsed Field Ablation Technology: Not a Flash in the Pan

The annual Atrial Fibrillation (AF) Symposium was held virtually this year for the first time due to the COVID-19 pandemic. Dr. Jeremy Ruskin and colleagues pulled off an incredible 3-day virtual meeting from January 29-31, 2021. Over 6,000 people registered to hear over 100 faculty members share content related to the management of atrial fibrillation with a focus on mapping and ablation technologies as well as left atrial appendage occlusion devices. Although many of the presentations were prerecorded, which helped keep the program on time, presenters and moderators joined the program live for panel discussions and to answer audience questions. Most of the cases were performed live in EP labs all over the world.

Last year, the 25th annual AF Symposium was the breakout meeting for pulsed field ablation (PFA) technology.¹ This new energy source has the potential to quickly and permanently create transmural ablation lesions in a manner that could be highly selective for heart muscle, avoiding the risks of collateral injury to the esophagus and phrenic nerve. Multiple companies and centers are actively developing PFA recipes and delivery systems to perform ablation for atrial fibrillation. This year’s AF Symposium provided further evidence that PFA was not a “flash in the pan.” Eleven of the over 100 presentations were dedicated to PFA. Five of these presentations were given during a session that was entirely devoted to irreversible electroporation, and 5 represented half of the live cases. With about 10 percent of the program devoted to PFA, one wonders how many of the other presentations at the meeting will be relevant if PFA actually takes over as the primary energy source in the EP lab. Much of the program covered concepts and tools being developed to address the limitations and side effects of radiofrequency (RF) ablation for AF, such as high power/short duration RF delivery, surrogate measures of lesion formation, esophageal deviation devices, methods to measure tissue thickness, and advanced mapping systems. These topics could become obsolete.

Radiofrequency energy creates permanent, focal, controllable, well-circumscribed ablation lesions, and has revolutionized the treatment of arrhythmias caused by a discrete structure such as an accessory pathway. However, focal RF energy has limitations. Cryoenergy is commonly used on the outside of the heart by surgeons, and when delivered endocardially using a balloon-based system, it is highly effective at isolating the pulmonary veins. Ultra-low cryoablation might be even better. Laser energy can also be used effectively to ablate cardiac tissue. But PFA is exciting and works in a flash. It seems so quick and safe. Many have said it is “too good to be true.” Time will tell, but based on the presentations at the 2021 AF Symposium, PFA might be the real deal. 

Stay safe,

Bradley P. Knight, MD, FACC, FHRS

@DrBradleyKnight
Editor-in-Chief, EP Lab Digest

Disclosures: Dr. Knight reports that he is a consultant, speaker, investigator, and offers fellowship support for Abbott, Baylis Medical, Biosense Webster, Inc., BIOTRONIK, Boston Scientific, Medtronic, and SentreHEART. He has received compensation for serving as a consultant to CVRx, Inc.

1. Knight BP. The 25th annual AF Symposium: summary of the session on early stage and emerging new technologies and drugs. EP Lab Digest. 2020;20(3):6.