Hope, Hype, and Reality of Pulsed Field Ablation for Atrial Fibrillation

This NEJM editorial evaluates the ADVENT trial, which compared pulsed field ablation (PFA) to conventional thermal ablation for atrial fibrillation. Despite procedural advantages like shorter procedure times and near-complete pulmonary vein isolation (99.6%), arrhythmia-free outcomes at 1 year were comparable (PFA 73.3% vs. thermal 71.3%), suggesting stagnant efficacy. Safety features of PFA nonthermal cell destruction with myocardium selectivity, are promising, potentially reducing risks like atrioesophageal fistula. However, concerns remain: MRI-detected brain lesions (9% with PFA vs. 0%), coronary artery spasm, and rare phrenic-nerve injuries reported in registries. The editorial emphasizes that while PFA may revolutionize procedural safety, efficacy remains tied to the incomplete understanding of atrial fibrillation mechanisms. Future multicenter data and long-term follow-up are needed to determine whether PFA truly shifts therapeutic outcomes.

This NEJM editorial evaluates the ADVENT trial, which compared pulsed field ablation (PFA) to conventional thermal ablation for atrial fibrillation. Despite procedural advantages like shorter procedure times and near-complete pulmonary vein isolation (99.6%), arrhythmia-free outcomes at 1 year were comparable (PFA 73.3% vs. thermal 71.3%), suggesting stagnant efficacy. Safety features of PFA nonthermal cell destruction with myocardium selectivity, are promising, potentially reducing risks like atrioesophageal fistula. However, concerns remain: MRI-detected brain lesions (9% with PFA vs. 0%), coronary artery spasm, and rare phrenic-nerve injuries reported in registries. The editorial emphasizes that while PFA may revolutionize procedural safety, efficacy remains tied to the incomplete understanding of atrial fibrillation mechanisms. Future multicenter data and long-term follow-up are needed to determine whether PFA truly shifts therapeutic outcomes.