Pulsed Field Ablation
Pulsed field ablation (PFA) can offer advantages over other ablation techniques for people with heart rhythm disorders.
What You Need to Know What You Need to Know
- Pulsed field ablation is a minimally invasive procedure to treat atrial fibrillation (AFib) and other arrhythmias.
- Instead of thermal energy used with traditional ablation techniques (radiofrequency and cryoablation), PFA uses electrical pulses, which allows for improved safety and efficiency. It also allows ablation in areas near the nerves or the esophagus that are deemed higher risk with thermal ablation.
- PFA is typically performed under general anesthesia, and patients can usually go home the same day.
What is pulsed field ablation?
Pulsed field ablation (PFA) is a minimally invasive catheter ablation technique used to treat atrial fibrillation and other forms of heart arrythmias. PFA uses brief, high-energy electrical pulses to destroy (ablate) targeted heart tissues to help reduce the frequency of abnormal heart rhythms.
PFA works through electroporation — a process during which electrical impulses create tiny holes in the cell membrane. If enough energy is applied, this can cause irreversible cell damage, which is the goal of cardiac ablation.
How is PFA different from traditional ablation techniques?
Traditional heart ablation techniques include radiofrequency and cryoablation. They use thermal (heat or cold) energy to destroy tissues, while PFA uses electrical pulses. While thermal ablation of atrial fibrillation is effective, thermal energy can damage the esophagus and nerves to the lungs (diaphragm) and to the stomach. Thermal ablation can also cause dangerous narrowing of the pulmonary veins. The main advantage of PFA is that it limits the risk of injury to the organs surrounding the heart.
In addition to these reduced risks, PFA is also generally more efficient than traditional ablation. This means less time under general anesthesia.
| Comparison Category | Pulsed Field Ablation | Traditional Ablation (radiofrequency and cryoablation) |
|---|---|---|
| Mechanism of action | Electroporation | Thermal injury (heat or cold) |
| Procedure time | 1–3 hours | 3–5 hours |
| Risk of collateral damage | Lower: Injury to the esophagus, phrenic nerve and pulmonary veins is dramatically reduced. | Higher: The thermal burn or freeze can sometimes damage the esophagus, the phrenic nerve and the pulmonary veins. |
| Effectiveness | Newer modality; clinical trials show it is at least as effective as traditional ablation in treating arrhythmias. | Well-established procedure with similar effectiveness to PFA. |
Who performs PFA?
PFA is performed by an electrophysiologist — a specialist in the electrical activity of the heart. The care team may also include nurses, technicians, anesthesiologists and heart imaging experts.
Who can benefit from PFA?
Studies have shown that early treatment of AFib tends to lead to better outcomes, including improved symptoms and better quality of life. Because of the improved safety and efficiency of PFA, most centers use it as their preferred tool for AFib ablation.
PFA can be a treatment option for people who:
- Have paroxysmal or persistent AFib, especially if they are experiencing symptoms from atrial fibrillation.
- Have both AFib and congestive heart failure. Research shows these patients greatly benefit from ablation, especially if AFib is the cause of the heart failure.
- Cannot tolerate or do not wish to take AFib medications. Although doctors usually consider medications before recommending a procedure such as an ablation, in many cases ablation may be appropriate as the first-line treatment.
If you fall into any of these categories or think PFA may be a good treatment for you, talk to an electrophysiologist. They can advise not only on PFA, but also on overall management of arrhythmia, which may include lifestyle modifications such as addressing sleep apnea and reducing use of harmful substances. Seeing an electrophysiologist has been shown to greatly benefit people in the long-term management of arrhythmia.
Preparing for PFA
Once you and your doctor decide that PFA is the right treatment for you, the preparation is simple:
- Your doctor will review your current medications and instruct you on whether they need to be adjusted leading up to the procedure.
- Your doctor may order tests to get a better look at the heart and assess your overall health. The tests may include:
- Echocardiogram
- Cardiac CT scan or MRI
- Blood tests
What happens during PFA?
PFA is a minimally invasive procedure typically performed through the femoral veins in the legs, which means it does not need large incisions to the chest to access the heart. Instead, doctors use a variety of catheters that get threaded through a vein and guided to the heart.
PFA is performed under general anesthesia. Before starting the procedure, your doctor may perform a transesophageal echocardiogram — an ultrasound of the heart from inside the esophagus — or a CT scan to check for blood clots as well as create a 3D map of the heart.
During pulsed field ablation:
- A doctor makes a small puncture with a needle and inserts a catheter through a vein — typically the femoral vein near the groin, but other veins may be used.
- A doctor guides the catheter through the body’s circulatory system toward the heart using imaging such as X-ray, ultrasound or 3D mapping systems.
- The catheter is positioned within the heart near the area that should be ablated. For treatment of AFib, the catheter is often positioned near the openings of the pulmonary veins to create lesions that block abnormal electrical signals from these veins (a procedure called pulmonary vein isolation).
- Brief electrical pulses are delivered through the electrodes at the end of the catheter. Doctors may rotate or reposition the catheter to treat all target areas. Usually, the same areas are treated with PFA at least twice to ensure the effects are long lasting.
- Doctors confirm that abnormal electrical pulses in the heart have been blocked — this effect should be immediate.
- The catheters are removed, and the incision site is sealed.
PFA Risks and Complications
PFA shares these risks with other catheter ablation procedures, though these risks are lower with PFA:
- Damage to blood vessels and bleeding
- Blood clots, which can lead to stroke
- Puncture of the heart wall
- Buildup of fluid around the heart (pericardial effusion)
Complications that are specific to PFA are rare, but include:
- Red blood cell destruction (hemolysis), which can affect kidney function
- Spasms of the coronary artery
Research shows that PFA lowers the risk when it comes to:
- Esophagus damage
- Phenic nerve damage
- Pulmonary vein stenosis
Recovery After PFA
People usually go home the same day or the next day after the PFA procedure. In the first few weeks after the procedure, patients may expect:
- Soreness at the incision site
- Fatigue
- Chest pain or discomfort
- Occasional irregular heartbeats: This is normal while the heart tissue is healing.
Your care team will provide all necessary instructions and have you schedule follow-up visits to monitor your progress. The effectiveness of the procedure is usually evaluated around the three-month mark. By this time, the heart tissue should have fully healed, and irregular heartbeats should stop or diminish.
Your doctor may adjust or remove some of your medications if your symptoms significantly improve. In some cases, a repeat ablation may be necessary.
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