Pulsed field ablation (PFA) is a non-thermal (not using extreme heat or cold) method of biological ablation (removal of structure or functionality) utilizing high-amplitude pulsed (microsecond duration)

electric field An electric field (sometimes called E-field) is a field (physics), physical field that surrounds electrically charged particles such as electrons. In classical electromagnetism, the electric field of a single charge (or group of charges) descri ...

s to create irreversible electroporation in tissues. It is used most widely to treat tumors (

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

) or

cardiac arrhythmias Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – above 100 beats ...

Background

Atrial fibrillation Atrial fibrillation (AF, AFib or A-fib) is an Heart arrhythmia, abnormal heart rhythm (arrhythmia) characterized by fibrillation, rapid and irregular beating of the Atrium (heart), atrial chambers of the heart. It often begins as short periods ...

frequently results from bursts of

tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...

that originate in muscle bundles extending from the atrium to the

pulmonary vein The pulmonary veins are the veins that transfer Blood#Oxygen transport, oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four ''main pulmonary veins'', two from each lung that drain into the left atrium of the h ...

s. Pulmonary vein isolation ablation technology has used thermal methods (

radiofrequency ablation Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor, sensory nerves or a dysfunctional tissue is ablated using the heat generated from medium fre ...

or, less often,

cryoablation Cryoablation is a process that uses extreme cold to destroy tissue. Cryoablation is performed using hollow needles (cryoprobes) through which cooled, thermally conductive fluids are circulated. Cryoprobes are positioned adjacent to the target in ...

) to destroy pulmonary vein cells. As with thermal methods of ablation, in pulsed field ablation, a thin, flexible tube (

catheter In medicine, a catheter ( ) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. ...

) is inserted into a blood vessel in the

groin In human anatomy, the groin, also known as the inguinal region or iliac region, is the junctional area between the torso and the thigh. The groin is at the front of the body on either side of the pubic tubercle, where the lower part of the abdom ...

and threaded up into the heart to ablate the areas of the pulmonary vein causing excessively rapid electrical signals.

Advantages

A major reason for recurrence of atrial fibrillation after ablation has been the belief of electrical pulmonary vein reconnection, which has not been seen for PFA. In one study, atrial fibrillation recurrence in the thermal ablation group was 39% compared to 11% in the PFA group. PFA can achieve pulmonary vein isolation faster than other ablation methods. Compared to radiofrequency ablation, PFA produces lesions of greater uniformity.

Safety

Cell death following PFA is usually due to

apoptosis Apoptosis (from ) is a form of programmed cell death that occurs in multicellular organisms and in some eukaryotic, single-celled microorganisms such as yeast. Biochemistry, Biochemical events lead to characteristic cell changes (Morphology (biol ...

, which is a far less damaging and inflammatory form of cell death than

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...

. In contrast to thermal methods of ablation, PFA specifically kills cardiomyocytes (cardiac muscle cells) without injuring surrounding tissues. Thermal ablation methods can damage the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

phrenic nerve The phrenic nerve is a mixed nerve that originates from the C3–C5 spinal nerves in the neck. The nerve is important for breathing because it provides exclusive motor control of the diaphragm, the primary muscle of respiration. In humans, t ...

, and coronary vessels (as high as 5% ), which are spared by PFA. One study showed an overall complication rate of 0.7% for PFA and no occurrence of phrenic nerve, esophageal, or pulmonary vein injury.

Challenges

Because PFA is a relatively newer ablation technique, there is a lack of uniformity in the parameters for its delivery. Better standardization could help reduce instances of coronary artery spasm and pulmonary artery hemorrhage, which can occur. The equipment cost and lack of specialized training have limited the widespread use of PFA, making it unavailable to many patients. Recent (2024) comparisons of PFA with thermal methods have shown reduced time spent in surgery, but no superiority in safety and no better reduction of atrial fibrillation. When used in areas other than the pulmonary vein, injuries have been seen.

Commercial

There are several commercial systems in use or pending release: * FaraPulse by Boston Scientifi

* PulseSelect by Medtroni

* Varipulse by Biosense Webste

References

{{reflist

External links

Cardiac Ablations for Atrial Fibrillation: What to Expect After Your Procedure
o
Massachusetts General Hospital

Focal Pulsed Field Ablation Guided by Contact & Noncontact Mapping
on AF Symposium 2022 Cardiac electrophysiology Cardiac procedures