Redo Ablation After Failed PFA—Go for Hybrid, Stick With Pulses or Switch to Thermal?

Interview With Frank Cuoco, MD, MBA, MS

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Interview by Jodie Elrod

Frank Cuoco, MD, MBA, MS, co-director of Cardiac Electrophysiology and the Director of Cardiovascular Outreach for HCA Trident Health in Charleston, South Carolina, discusses his upcoming roundtable at the 2026 Western Atrial Fibrillation Symposium.

To start, could you introduce yourself and briefly describe your clinical or research background as it relates to atrial fibrillation (AFib) and ablation strategies?

My name is Frank Cuoco. I am a cardiac electrophysiologist, and I have been practicing for almost 20 years now. I have an extensive research background that dates back to my time at the Medical University of South Carolina. I'm currently with HCA in the South Atlantic Division in Charleston, South Carolina. We have a robust research program that focuses mostly on ablation research centered around AFib as well as research involving left atrial appendage closure and stroke prevention strategies for AFib. We also perform some novel work with some of my co-membership and co-meeting attendees on novel concepts in AFib focusing on management of hypertension and concepts such as renal denervation in patients with AFib.

Your upcoming roundtable at Western AFib focuses on decisions following a failed pulsed field ablation (PFA) procedure. From your perspective, what are some of the key considerations that clinicians should keep in mind when determining whether to pursue a hybrid approach, repeat PFA, or transition to a thermal modality?

Yes, after failed PFA, a lot of us are trying to figure out what to do. We thought that PFA was our “holy grail” for some of these ablations because we could do much more ablation in patients with recurrent AFib and especially recurrent persistent AFib, allowing us to target either substrate or non-pulmonary vein (PV) triggers that in the past we may have not been able to safely ablate with thermal technologies. So, we've used some of these PFA technologies in this arena, but when patients recur after that, then it becomes more challenging to figure out what to do. We need to figure out, in a lot of cases, if these are recurrent atrial flutters that are going to be easily amenable to repeat ablation or if they are truly AFib from other non-PV sites, which may be difficult to get with our current PF and sometimes even thermal technologies.

One of the limitations of PFA is that, in some cases, we're not able to get deep enough lesions. That can also be an issue with thermal technologies, but sometimes using a combined approach will allow us to achieve deeper lesions and perhaps better success in some patients. 

As you prepare for Western AFib 2026, what aspects of this discussion—and the meeting overall—are you most excited to explore with your colleagues and attendees?

First, I want to say that this is going to be my first Western AFib meeting, so I'm very excited. I am thankful to the organizers and Dr Marrouche for the invitation to participate. I'm excited to attend because this meeting is a little more intimate than some of the bigger meetings. This is a large international meeting, but it also offers a great opportunity to spend more time in a smaller setting focusing on the topics that are really important to my practice and to a lot of electrophysiologists’ practices, which is, how to best manage AF. So, it will be great to hear from my colleagues and from other attendees about what their approaches are and what they have encountered.

I enjoy sharing my cases and experiences with them to learn how others might have approached them and what ideas they may have for these more challenging cases. I find it's best to present your toughest cases and your failures. Everyone knows what it's like to have a success, but the difficult cases are really what gets us up and going in the morning and helps us be better. I always get a chance to learn from my colleagues in that setting. So, I'm really excited about this meeting and I think it's going to be a great opportunity.

The transcripts have been edited for clarity and length.