Pulse Field Energy (of Dreams): Is it the Future of Ablation?

Catheter ablation is the cornerstone of management of cardiac arrhythmias. Thermal energy sources such as radiofrequency energy and cryoenergy have proven to be effective and safe for ablating myocardial tissue responsible for the initiation and maintenance of cardiac arrhythmias. However, thermal energy causes significant collateral damage because of ablation-related coagulation necrosis and inflammation. Phrenic nerve damage, pulmonary vein stenosis, and esophageal mucosal injury that can result in atrio-esophageal fistula are some of the most concerning complications associated with thermal ablation. Pulsed field energy is a novel energy source that can cause selective, nonreversible electroporation of cardiac myocytes, resulting in apoptotic cell death. Early preclinical and clinical studies indicate that pulsed field ablation (PFA) is as effective as thermal energy for ablation of atrial fibrillation. The tissue-specific nature of this energy source causes minimal collateral damage, resulting in a favorable safety profile. PFA is also being evaluated for the ablation of non-atrial fibrillation supraventricular arrhythmias and ventricular arrhythmias. This review summarizes the rapid development of a wide array of PFA systems and its developing role as the primary modality for catheter ablation. PFA offers the promise of tissue- and patient-specific ablation solutions for cardiac arrhythmias.