Pulsed Field Ablation (PFA)

Pulsed Field Ablation, or PFA, is an FDA-approved type of ablative therapy to treat atrial fibrillation (AFib). It uses electrical pulses to destroy heart tissue that causes the misfiring of the heart muscle in the left upper chamber of the heart, or left atrium. That misfiring leads to AFib, which can cause stroke and other complications.

Traditionally, ablation is achieved by applying extreme heat, as with radiofrequency (RF) ablation, or extreme cold, as with cryoablation, to destroy the tissue. During PFA, an electrophysiologist—a physician who specializes in heart rhythm disorders—threads a catheter up into the heart through a blood vessel in the groin. Using mapping technology and imaging devices in the procedure room, the physician guides the catheter to the area of the left atrium where the arrhythmia originates. Then high-voltage pulses are delivered to the area, creating microscopic pores in the heart tissue to disrupt the misfiring signals.

This ablative approach, which doesn’t use extreme temperatures to destroy tissue, minimizes the risk for potential damage to nearby critical structures. These structures include the pulmonary vein leading to the lungs, the esophagus and the phrenic nerve that controls the diaphragm to regulate breathing. During traditional RF ablation and cryoablation, these structures must be monitored frequently to ensure that they are not damaged.

With PFA, the high-voltage electrical pulses are delivered in rapid succession and can be targeted to a specific area within the atrium, sparing nearby tissue. Because monitoring of adjacent structures is not required, the procedure time has been reduced to under one hour—much quicker than with traditional RF ablation or cryoablation. Research has shown that because these vital structures are not impacted by the electrical pulses and because of the shortened duration that patients must remain under anesthesia, it is comparatively safer than traditional ablation methods. Also, the lasting effects of this procedure mirror those of RF ablation and cryoablation.

As with any heart procedure, risks exist. The transcatheter, endovascular approach makes this procedure minimally invasive, significantly reducing risks. Studies have shown that the highest risk with PFA is from pericardial tamponade, when fluid accumulates in the sac that surrounds the heart and prevents the heart from properly contracting. To minimize the tamponade risk, intracardiac echocardiography monitors for fluid buildup, known as pericardial effusion, throughout the procedure. Other documented risks include stroke, phrenic nerve injury and transient ischemic attack. These complications occurred in less than 1% of cases performed. Groin access complications occurred in 1-4% of cases.

PFA begins with general anesthesia for maximum patient comfort, followed by a transesophageal echocardiogram, or TEE, to ensure there are no blood clots in the heart that could cause complications. The doctor then accesses the femoral vein through a small puncture in the groin and uses imaging and mapping technology to guide the catheter, or hollow tube, up to the heart.

Within the heart, the catheter penetrates the septal wall from the right atrium to the left atrium. There, high-voltage electrical pulses delivered through the catheter destroy tissue to disrupt the misfiring of the heart muscle that creates the arrhythmia.

After about an hour, the procedure is finished. Patients must remain flat for about two hours to prevent bleeding from the vein puncture. After moving around for one to two additional hours, most patients go home. The next day, patients are permitted to work in a non-strenuous capacity and can return to full activity six days after the procedure. Patients are evaluated by the doctor in a clinic setting two weeks later.

Studies have shown that the efficacy and long-term management of paroxysmal and persistent atrial fibrillation with PFA is comparable to that of traditional RF ablation and cryoablation. PFA, however, may be a safer alternative due to requiring less time under anesthesia and minimizing damage to critical structures within the chest.

At Memorial Hermann, we’ve made significant investments into managing heart rhythm disorders like AFib. In addition to our dedicated electrophysiology labs, which house the latest technology for minimally invasive endovascular procedures, our affiliated heart and vascular specialists have also tested some of the devices and techniques that have been or will soon be approved by the FDA for the treatment of AFib. Combined, the technology infrastructure and experienced clinicians position Memorial Hermann on the forefront of cardiac electrophysiology care.

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