Treating atrial fibrillation with pulsed field ablation

The understanding of atrial fibrillation (AFib) has evolved significantly across the decades. A standard of AFib treatment, ablation therapy targets the pulmonary veins, where the condition typically originates. But in the last 25 years or so, it’s become clear that AFib is associated with structural changes elsewhere in the heart that perpetuate worsening of the disorder.

“One of the most salient aspects of AFib is that it is so heterogeneous,” explains Matthew A. Bernabei, MD, Section Chief of Electrophysiology and Pacing, Lancaster General Hospital, in an episode of the Penn Medicine Physician Interviews podcast (see links below).

“Ablation has really pivoted over many years now to allow some flexibility in targeting not just the pulmonary veins, but potentially any other areas—in the left atrium, most commonly—that may also benefit from targeted ablation,” he adds.

To address the heterogeneity of AFib, Dr. Bernabei and his colleagues are performing targeted ablation with pulsed field ablation (PFA), the latest iteration of ablation technology.

Pulsed field ablation: Safer and more efficient

Radiofrequency ablation has been a mainstay of AFib treatment for decades.

More recently, cryoablation gained interest because it requires less point-by-point ablation, potentially covering a larger area of the atrium with fewer applications. Despite that promise, cryoablation has not significantly improved efficiency, Dr. Bernabei says.

PFA offers a contrast to both cryoablation and traditional radiofrequency ablation.

By using high-voltage electrical pulses to denude and compromise the cell membrane, PFA achieves effectiveness rates comparable to those of thermal ablation. Yet it can be performed more efficiently, significantly reducing procedural times.

Perhaps the most important feature of PFA, though, is its enhanced safety profile.

Using heat or cold to treat AFib is a balancing act: causing enough damage to the muscles to restore normal heart rhythm without putting nearby structures, such as the esophagus or phrenic nerve, at risk. Pulsed-field ablation specifically targets cells in the myocardium, reducing the risk of damage to nearby tissues.

“PFA’s most interesting attribute is that it tends to be cardio-selective,” explains Dr. Bernabei. “Safety first and foremost has improved, and that’s been a big sea change—and probably why PFA is garnering a lot of attention.”

The expanded safety profile expands the population of patients who might benefit from ablation but who weren’t considered good candidates for the procedure in the past. “When the tools that enable you to do this prove safer and more efficient, the bar gets lower, and therefore a larger swath of population and demographic of patients can be considered,” Dr. Bernabei says.

AFib treatment at Penn Medicine

Having participated in the pre-approval ADVENT clinical trial of the FARAPULSE Pulsed Field Ablation System (Boston Scientific), Penn Electrophysiology has been at the forefront of electrophysiology research and clinical care for decades, including a long history with PFA.

“I would encourage our colleagues, when they're seeing patients with AFib, to pick up the phone,” says Dr. Bernabei. “My colleagues across Penn Medicine are more than happy to expound on AFib because this is all we do every day, all day. We're happy to see these patients and try to figure out what the next best step is.”

Clinical consult and patient referral

To refer a patient to the Afib specialists at Penn Medicine, call the 24/7 provider-only line at 877-937-7366 or submit via the secure online referral form.

Episode: Targeting Atrial Fibrillation: Pulsed Field Ablation at Penn Medicine

Electrocardiologist Matthew A. Bernabei, MD, examines the history of ablation for atrial fibrillation and its latest iteration, pulsed field ablation, or PFA.

Listen to this episode on Apple Podcasts, Spotify or YouTube Music.