Pulsed Field Ablation (PFA) – The Next Big Thing in Afib Treatment?
If you have experienced Atrial Fibrillation Afib or other cardiac arrhythmias, you’ve undoubtedly heard about cardiac catheter ablation procedures. These exceptionally effective therapies have been the staple of Afib treatment over the past couple of decades. Catheter ablation technology is very straightforward – it uses thermal energy (heat or cold) to ablate or destroy problematic heart tissue. Using cardiac catheter ablation, the abnormal heart rhythm is dramatically improved in many cases, especially in paroxysmal or occasional Afib. With success rates approaching 80% in the well-selected patients, catheter ablation revolutionized arrhythmia treatment in its time.
Ablations are some of the most advanced procedures in modern medicine. Not only does ablation involve a minimally invasive catheter being threaded from a blood vessel in the thigh up to the heart, but this must be done with advanced guidance. What was once performed using radiation-based continuous X-ray, known as fluoroscopy, to guide the catheter is now done with safer and more precise ultrasound. Further, the same catheter system would have to deploy alternately heat or cold therapy to destroy problematic heart tissue.
However, even this advanced technology has its limitations. Deploying heat or cold therapy near sensitive tissue and structures like nerves and the esophagus can cause potential complications, even in the most experienced hands. While thermal damage to surrounding structures is a relatively uncommon concern, it cannot be ruled out.
What Is PFA, and Why Is It Better?
With PFA, the delivery mechanism remains essentially the same as thermal ablation – it uses a catheter to deliver the probe and ultrasound guidance to get there safely. Rather than using thermal energy like heat created by RF (radio frequency) waves or cold created by a balloon catheter, PFA uses new pulsed technology that hits the targeted tissue with a microsecond-long burst of high-voltage electricity. Doing this causes a phenomenon known as irreversible electroporation (IRE). This damages the outer shell of targeted cells, causing irreversible damage and collapse. Ultimately, these destroyed cells are absorbed into the surrounding tissue. As with a traditional thermal ablation, our advanced monitoring technology can tell us almost immediately if the procedure has been successful as we continue to monitor for errant heart signals.
A Faster Procedure
Another exciting aspect of pulse field ablation is how quick it is. To give you an idea of the progression of ablation technology, in the early days, ablation could take up to four hours or even longer. The time requirement was such that fatigue amongst the medical team was widespread. Initially, traditional continuous X-ray systems couldn’t handle the load required to complete the procedure. With more advanced catheter technology, better guidance systems, and incredible visualization through ultrasound technology, thermal ablations could be performed effectively and safely in as little as 60-90 minutes.
PFA can further reduce the time needed to perform the ablation, meaning patients require less time under anesthesia. This is particularly helpful for patients who are more sensitive to anesthesia and older patients who have a greater risk of side effects associated with being under. For example, PFA reduces procedural time by sending a single energy pulse to elegantly isolate the pulmonary veins. With older thermal technology, we were required to make multiple lesions around the pulmonary veins, which took time and were necessarily less precise. In the future, we may be able to eliminate general anesthesia for most patients – a top priority of researchers and clinical studies worldwide.
Is There Still a Place for Thermal Technologies?
The simple truth is that post-field ablation is a revolution in electrophysiology and will likely supplant thermal technologies as the gold standard in Afib treatment, especially when the posterior wall is treated. The results are similar while the risks are lower, and that’s precisely what we are looking for in our new technologies. RF or heat-based ablations will still play a role in certain arrhythmias, especially in treating the anterior wall of the heart.
However, from Dr. Tordini’s perspective, pulsed-field ablation will make cryoablation or cold therapy to ablate heart tissue obsolete.
The transition to PFA will take time because this new technology is in great demand, and many facilities are waiting to be equipped to offer PFA-based therapies. Fortunately, Dr. Tordini and Saint Joseph’s have this technology and already provide it to qualifying patients. Also, PFA has not yet been approved for other arrhythmias. We expect this will change within the next few years, and PFA will soon be available for a broader range of conditions.
If you have been diagnosed with atrial fibrillation, we encourage you to contact our office and meet with Dr. Tordini to learn more about the full gamut of treatment options, including pulsed-field ablation.