Pulsed Field Ablation Offers Breakthrough in Atrial Fibrillation Treatment – Surgical Techniques

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Image: Testing pulsed field ablation for the treatment of atrial fibrillation (Photo courtesy of NYU Langone)

Catheter ablation has long been recognized as an effective treatment for a wide variety of cardiac arrhythmias, but the therapy carries a risk of damaging surrounding tissue. Today, pulsed field ablation (PFA) is emerging as a new non-thermal energy source that may offer a safer alternative to conventional catheter ablation technologies. The PFA delivers ultra-short high voltage pulses to create lesions on targeted tissues. This mechanism is also known as electroporation because it causes temporary pore-like openings in cell walls, leading to death by apoptosis. Pulse frequency can be adjusted to target specific proteins in the cell membrane, leaving other tissue types unharmed.

Previously used in oncology to destroy specific types of tumors or to increase tumor permeability to chemotherapy drugs, PFA has recently been adapted for catheter ablation by a number of manufacturers. European regulators approved the first such device in January 2021, but the technology remains experimental in the United States. NYU Langone (New York, NY, USA) is currently conducting clinical trials of three different PFA cardiac ablation devices in patients with atrial fibrillation.

In the three trials testing devices developed by Medtronic, Farapulse, and Biosense Webster, primary outcomes include primary adverse events such as atrial-esophageal fistula and cardiac tamponade/perforation within seven days, and absence of documented atrial arrhythmia, atrial tachycardia or atrial flutter up to one year. Secondary outcomes include the number of patients who achieve acute procedural success, defined as confirmation of entry block into the targeted auricular pulmonary veins after adenosine/isoproterenol provocation, and change in the quality of life after ablation.

PFA could replace radiofrequency and cryoablation as the primary energy source for cardiac ablation. Eventually, it could be adapted beyond atrial fibrillation to other arrhythmias, including those involving the ventricles. However, many questions about the new technology remain, including the durability of the lesions produced by PFA, the safety compared to conventional counterparts, and which of the available catheters is optimal for a given application, such as paroxysmal or persistent atrial fibrillation.

“With traditional power sources, we spend a lot of our time trying to avoid collateral damage to nerves, blood vessels, lungs, or esophagus,” said Larry A. Chinitz, MD, director of the Heart Rhythm Center. “PFA offers hope for an instant, efficient, and heart-specific source of energy.”

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NYU Langone

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