Pulsed Field Ablation Is Shaking Up the World of EP Therapy

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Pulsed Field Ablation Is Shaking Up the World of EP Therapy

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For most of the last two decades, EP labs have relied primarily on two energy sources for cardiac ablation: radiofrequency and cryoablation. Radiofrequency uses heat to create controlled scar tissue, while cryoablation uses freezing temperatures.

Evyatar Nitzany has watched both technologies be used extensively during more than a decade in EP program leadership. Pulsed field ablation, or PFA, works differently. It uses short, high-voltage electrical pulses to create pores in cell membranes through a process known as electroporation.

Cardiac muscle cells are particularly sensitive to this effect compared with nearby structures such as esophageal tissue, phrenic nerve fibers, and vascular walls. That selectivity allows PFA to target the heart tissue being treated while limiting damage to surrounding tissue, which is one of the main reasons the technology has attracted so much attention in electrophysiology.

As PFA becomes more common in EP labs, the conversation is shifting from how the technology works to what it takes to use it well. Nitzany discusses what he’s seen as programs adopt PFA, including the training, workflow changes, and quality monitoring that come with introducing a new energy source.

Why has adoption moved as quickly as it has?

I haven’t seen a new energy source generate this much interest this quickly during my time in EP. Two complications every AF ablation program worries about – atrioesophageal fistula and phrenic nerve injury – are closely associated with thermal injury. Because PFA doesn’t rely on heat or freezing, its tissue selectivity changes that risk profile.

Procedure times can also become shorter once a team is comfortable with the workflow. Put those advantages together, and it’s easy to understand why many labs moved from evaluating the technology to making purchasing decisions within a few years.

That’s unusually fast in a field where new technology can take much longer to become part of everyday clinical practice.

What has to change operationally when a program brings PFA into the lab?

Usually more than people expect.

Bringing in PFA isn’t simply a matter of replacing one catheter with another. The generator and mapping system must integrate into the lab, the team has to adjust to a different pulse-delivery sequence and new safety checks, and scheduling may need to change as procedure and turnover times shift.

Inventory management changes as well. Most labs continue using radiofrequency and cryoablation while introducing PFA, at least initially, so the new technology adds another set of equipment and disposables to an inventory that already needs careful management.

I’ve generally seen smoother transitions when programs give their teams time to become comfortable with PFA while continuing to use the systems they already know. As experience builds, more of the caseload can move toward PFA when it’s clinically appropriate.

How does staff training and onboarding work for a new energy source like this?

The training process isn’t dramatically different from what a strong EP program would use when introducing a new mapping system or catheter platform.

Staff members who already work at an advanced level in the lab are often the first to train. They’re accustomed to connecting equipment, troubleshooting recording systems, operating stimulators during cases, and recognizing when something isn’t working as expected. Once they’re comfortable with the new generator and workflow, they can help train the rest of the team.

Physicians also need experience with the technology before using it independently, including a series of proctored cases.

In programs I’ve worked with, we typically allow several weeks before a new team member or a newly introduced technology is fully integrated into the lab. PFA hasn’t changed the need for that deliberate onboarding process.

What does PFA mean for quality tracking and outcomes monitoring?

Programs need to make sure they’re measuring the outcomes that prompted them to adopt the technology.

If a program continues tracking only the same measures it used for radiofrequency ablation, it may miss important information about how PFA is performing in its own patient population. Esophageal injury and phrenic nerve outcomes, for example, should be monitored so the program can see whether the safety profile reported in published research is also showing up in its own results.

Registry participation becomes particularly useful during a transition like this. Programs participating in resources such as the National Cardiovascular Data Registry AF Ablation Registry can compare their experience with data from other facilities using the technology.

Published studies tell you how a technology performed in a trial or larger population. A program still needs to know what’s happening in its own lab.

Is the safety profile as clear an advantage as it sounds?

PFA appears to offer meaningful safety advantages for certain types of collateral injury, but it’s important to be specific about what the evidence supports.

PFA isn’t a cure for atrial fibrillation, and long-term outcomes still depend heavily on factors such as patient selection and operator experience. The evidence supporting PFA continues to grow, but it doesn’t yet have the multi-decade track record of radiofrequency ablation.

Early experience has been especially encouraging in reducing esophageal injury, persistent phrenic nerve injury, and pulmonary vein stenosis. That’s a meaningful benefit, but it shouldn’t be interpreted as evidence that every risk associated with an AF ablation procedure has disappeared. PFA has its own potential complications, including coronary artery spasm and hemolysis, in addition to risks associated with catheter ablation generally.

Patients still need to be selected appropriately, procedures still need to be performed carefully, and programs still need to monitor their outcomes.

What should programs consider when making the switch?

Buying the equipment is often the easier part. The bigger challenge is making sure the program itself is ready to use it.

Training, staffing, inventory, scheduling, and quality tracking must all account for the new technology. If PFA is simply added to a workflow built entirely around radiofrequency ablation, teams can end up trying to use a new system without changing the surrounding processes.

I’ve seen programs make a sound purchasing decision but underestimate the operational preparation needed afterward. When results are inconsistent, the problem isn’t necessarily the technology. Sometimes the lab hasn’t had enough time or support to incorporate it properly.

Giving the team that time is part of adopting PFA successfully.

Where do you see this heading over the next few years?

I expect PFA to account for a growing share of first-time ablation procedures as more systems enter the market and more physicians and EP teams gain experience with the technology.

I don’t expect that to mean the disappearance of radiofrequency or cryoablation. EP labs will continue to encounter patients and procedures where those technologies remain useful, and having several options gives physicians more flexibility in choosing the approach that fits the case.

I’ve watched EP programs adapt to new technologies before, and the strongest transitions usually happen when the work outside the procedure gets as much attention as the technology itself. The equipment may be new, but the need for good training, thoughtful implementation, careful quality tracking, and an experienced team hasn’t changed.