Early Clinical Experience and Outcomes With PFA for Atrial Fibrillation
Key Summary
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Pulsed field ablation (PFA) represents a major advance in AF ablation, using non-thermal electroporation for myocardial selectivity and reducing complications, with <1% adverse events reported in the MANIFEST-17k study.
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Efficacy is durable and comparable to RF, with ~70–78% 12-month freedom from AF and ~73% at 4 years, plus meaningful reductions in AF burden and downstream healthcare use.
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Workflow efficiency is significantly improved, cutting procedure times by up to 1 hour and enabling same-day discharge.
Atrial fibrillation (AF) ablation has evolved from direct current to a refined, scalable one-shot system, and pulsed field ablation (PFA) represents its most significant leap yet. The latest evidence positions PFA as a transformative advance in safety, efficiency, and scalability.
From Direct Current to Pulsed Field: A Technological Leap
Over the past 4 decades, AF ablation has evolved from its origin in direct current ablation to point-by-point radiofrequency (RF), cryoballoon systems, contact-force catheters, and now PFA. The adoption of the cryoballoon in 2010 was notable in that it transformed ablation into a scalable procedure, albeit a complex one; PFA took this innovation further by condensing it into a “one-shot system.”
Importantly, unlike thermal energy, PFA uses non-thermal electroporation, designed to selectively ablate myocardial tissue while sparing adjacent structures.1 This allowance for precision addresses major historical complications of thermal ablation, including esophageal events, pericardial tamponade, pulmonary vein stenosis, phrenic nerve injury, and stroke. To this end, in the 2024 MANIFEST-17k study of over 17 600 patients, major adverse events were reported at a rate of less than 1%.2
Clinical Outcomes: Efficacy and AF Burden
Major trials have consistently demonstrated the noninferiority of PFA to RF for AF recurrence (≈70%-78% freedom from recurrence at 12 months by FDA-defined 30-second criteria),3-5 and follow-up at 4 years has shown a durable success rate of 72.8%.6
Additionally, compared with thermal treatment, PFA appears to reduce AF burden, not just recurrence. Even small absolute reductions (≈0.1%) translate into meaningful improvements in hospitalizations, quality of life, repeat ablation rates, and cardioversion number.7
Efficiency Gains: Shorter Procedures, Fewer Admissions
The use of PFA has resulted in a dramatic reduction in procedure times, often 45 to 60 minutes—roughly half that of traditional RF workflows. Many centers are also replacing cardioversion admissions with same-day ablation strategies.
Additional efficiency advantages include minimal irrigation requirements, reduced diuretic use, and lower post-procedure issues relating to heart failure.
A Word of Caution: Avoid Overablation
MRI data demonstrate excellent lesion sets with pulmonary vein isolation (PVI) alone. However, aggressive ablation to the posterior wall may reduce atrial function and strain. Selective, tissue-sparing strategies remain critical.
Bottom Line
PFA is rapidly becoming the standard of care for AF ablation due to its safety profile, procedural efficiency, and durable AF burden reduction. For interventional cardiologists collaborating with EP colleagues, understanding PFA’s clinical impact is increasingly essential as integrated cardiovascular care models evolve.
Nassir F. Marrouche, MD, is the Director of the Tulane University Heart and Vascular Institute in New Orleans, Louisiana.
References
- Reddy VY, Neuzil P, Koruth JS, et al. Pulsed field ablation for pulmonary vein isolation in atrial fibrillation. J Am Coll Cardiol. 2019;74(3):315-326. doi:10.1016/j.jacc.2019.04.021
- Ekanem E, Neuzil P, Reichlin T, et al. Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17K study. Nat Med. 2024;30(7):2020-2029. doi:10.1038/s41591-024-03114-3
- Duytschaever M, De Potter T, Grimaldi M, et al; inspIRE Trial Investigators. Paroxysmal atrial fibrillation ablation using a novel variable-loop biphasic pulsed field ablation catheter integrated with a 3-dimensional mapping system: 1-year outcomes of the multicenter inspIRE study. Circ Arrhythm Electrophysiol. 2023;16(3):e011780. doi:10.1161/CIRCEP.122.011780
- Reddy VY, Gerstenfeld EP, Natale A, et al; ADVENT Investigators. Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med. 2023;389(18):1660-1671. doi:10.1056/NEJMoa2307291
- Reddy VY, Calkins H, Mansour M, et al; AdmIRE Trial Investigators. Pulsed field ablation to treat paroxysmal atrial fibrillation: safety and effectiveness in the AdmIRE pivotal trial. Circulation. 2024;150(15):1174-1186. doi:10.1161/CIRCULATIONAHA.124.070333
- Reddy VY, Gerstenfeld EP, Mountantonakis SE, et al; ADVENT-LTO Study Investigators. Pulsed field ablation versus conventional thermal ablation for paroxysmal atrial fibrillation: 4-year outcomes in the ADVENT-LTO study. Nat Med. 2026. doi:10.1038/s41591-026-04246-4
- Reddy VY, Mansour M, Calkins H, et al; ADVENT Investigators. Pulsed field vs conventional thermal ablation for paroxysmal atrial fibrillation: recurrent atrial arrhythmia burden. J Am Coll Cardiol. 2024;84(1):61-74. doi:10.1016/j.jacc.2024.05.001
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