Introduction
Atrial fibrillation (AF) is the most prevalent sustained
cardiac arrhythmia. AF increases stroke risk and
cardiovascular mortality. Atrial fibrillation was managed with
antiarrhythmic drugs with limited efficacy. Recently, catheter
ablation is evolving with technological advances. Pulsed field
ablation (PFA) is a revolutionary technique which has gained
importance in interventional electrophysiology because of its
safety and efficacy [1]. PFA is a novel non-thermal ablative
modality with considerable safety and efficacy, for catheter
ablation of atrial fibrillation. Several studies have
demonstrated that progression of atrial fibrillation can be
prevented by early ablation. The patient no longer requires to
fail antiarrhythmic drugs before receiving ablation. In the
European Real World Outcomes with Pulsed Field Ablation
registry, freedom from atrial fibrillation/atrial tachycardia
recurrence after 1 year was similar in patients with prior
failed antiarrhythmic drug therapy compared to patients
undergoing pulsed field ablation as the first-line treatment
[2].
PFA - Effective treatment for AF
Pulsed field ablation is an important treatment for atrial
fibrillation. In the Safety and Clinical Performance Study of
Catheter Ablation with the Centauri System for Patients with
Atrial Fibrillation, one year freedom from atrial arrhythmia
outcomes was reported using monopolar PFA delivered through
contact force-sensing focal catheters [3].
Pulsed field ablation is a novel cardiac ablation modality
which uses ultra-rapid electrical pulses to cause cell death
by irreversible electroporation, disrupting cell membranes
selectively within myocardial tissue. Thermally mediated
complications can be avoided by using PFA in atrial
fibrillation. In the MANIFEST-PF (Multi-National Survey on the
Methods, Efficacy, and Safety on the Post-Approval Clinical
Use of Pulsed Field Ablation) registry, ablation using pulsed
field energy was effective in 78% of patients [4].
In the treatment of atrial fibrillation, pulsed field ablation
reduces the complications associated with conventional thermal
modalities, while maintaining efficacy. AdmIRE (Assessment of
Safety and Effectiveness in Treatment Management of Atrial
Fibrillation with the Bosense-Webster Irreversible
Electroporation Ablation System), a multicenter study,
confirmed the safety and effectiveness of the variable-loop
PFA catheter, with low fluoroscopy exposure [5]. In the PULSED
AF study (Pulsed Field Ablation to Irreversibly Electroporate
Tissue and Treat AF) patients with paroxysmal or persistent
symptomatic atrial fibrillation refractory to class I or III
antiarrhythmic drugs were treated with pulsed field ablation.
This study demonstrated low rate of adverse events and
provided effectiveness consistent with established ablation
technologies [6].
The inspIRE study (Study for Treatment of Paroxysmal Atrial
Fiban improvedn by Pulsed-field Ablation System with
Irreversible Electroporation), confirms the safety and
effectiveness of pulmonary vein isolation with pulsed-field
ablation using a variable-loop catheter with three-
dimensional mapping integration: An optimal number of PFA
applications resulted in improved one year success rate of
about 80% [7]. PFA has the capability to create rapid,
selective lesions in myocytes and it provides enhanced safety,
reduced procedural times and comparable efficacy to thermal
ablation [8,9]. Pulmonary vein isolation is an important
strategy for the treatment of paroxysmal atrial fibrillation.
The FARA-Freedom Study evaluated the long-term efficacy and
safety of PFA using the pentaspline catheter for paroxysmal
atrial fibrillation.
Pulmonary vein isolation using a pentaspline PFA catheter was
effective in treating patients with paroxysmal atrial
fibrillation and demonstrated favourable safety [10]. PFA has
the ability to achieve pulmonary vein isolation rapidly and
with minimal complications. PFA will reduce procedure times
and there is lower incidence of esophageal and phrenic nerve
damage [1]. In the PLEASE-AF study, novel hexaspline PFA
catheter demonstrated pulmonary vein isolation with excellent
safety profile [11]. The PFA system proved to be fast, safe
and effective in patients with paroxysmal and persistent
atrial fibrillation [12].
Conclusion
Atrial fibrillation is associated with increased morbidity and
mortality. Catheter ablation is the single best therapy for
AF. PFA has emerged as the novel non-thermal energy source,
which causes irreversible electroporation of cardiomyocytes
without damaging adjacent structures. This will prevent the
non-selective damage associated with traditional thermal
ablation methods like radiofrequency or cryoablation. PFA
offers safer, faster and effective treatment for atrial
fibrillation.
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