New Pulsed-Field Ablation Device Found Effective at 1 Year

The intervention techniques evolve

[www.medscape.com]

It is still early days, but I'm a bit concerned that the so-far fairly consistent data reported shows that PFA shows no/barely a statistical improvement over the success of an ablation compared to RF. While the technique has obvious benefits, it still needs some thought and ingenuity to achieve even a 5% improvement over long-term, durable, results.

PFA's main claim to fame is improved safety, not improved efficacy.

I keep getting challenges and comments over at Mayo Community Connect forums about PFA. Someone is touting it highly, or bigly if you prefer, and many come to that forum asking how good it is and that their EP wants to use it. I point out that, even though it's early innings, the improvement PFA offers lies in its safety over other forms of ablation, but that it hasn't shown a marked improvement in success at one year. I do take pains to point out, as well, that this means to the analytical mind that the application of it, i.e., the skill and experience of the practitioner, is what counts most if you're looking for successful ablations.

Quote
gloaming
the skill and experience of the practitioner, is what counts most if you're looking for successful ablations.

I think that statement is 100% correct and it remains correct if you change "ablations" to any other medical procedure. All the top EPs are using PFA now but they're mostly all still using RF too because PFA can't address every area of the heart and top EPs do more than just a PVI.

Quote
Carey

the skill and experience of the practitioner, is what counts most if you're looking for successful ablations.

I think that statement is 100% correct and it remains correct if you change "ablations" to any other medical procedure. All the top EPs are using PFA now but they're mostly all still using RF too because PFA can't address every area of the heart and top EPs do more than just a PVI.

And, RF has a more enduring therapeutic effect for at least one aspect of ablation—I researched this because it was applicable to me. If they ablate the autonomic ganglia (and they often do as they can be an Afib trigger area) this tends to enhance sympathetic tone, which is welcome if your parasympathetic tone is too high. In PFA ablations this effect lasts only a year or less, whereas with RF it lasts much longer and perhaps permanently.

It would be good for me to see a paper on this, Daisy. Would you happen to recollect when/where this might have been posted?

I found this (arguably dated now):

[www.jacc.org]



Edited 1 time(s). Last edit at 07/04/2025 09:56PM by gloaming.

Quote
gloaming
It would be good for me to see a paper on this, Daisy. Would you happen to recollect when/where this might have been posted?

I found this (arguably dated now):

[www.jacc.org]

This looks like a similar article to the one that I found earlier, but I don't have the reference at hand to my earlier research. The reason I was researching this is because pre-ablation, I had very high vagal tone which was causing a form of Dysautonomia where my BP would drop precipitously on standing. In practice that meant that I would start to faint after about 5 minutes standing--very inconvenient! After my RF ablation with Natale, this condition was much improved.

I wonder, depending on what is going on IF sometimes they use a little bit of both RF and PFA? Since more than one catheter is used. Or do PFA and then go back up thru with the other and finish up with RF something that PFA couldn't adequately address?

Yeah, I think it's typically do the PVI with PFA and then go back in with RF to ablate other problem areas PFA can't address.

Thanks again Carey, that is very good to know that highly skilled EP will do as much as possible on this first go round vs maybe a regular EP might just tackle the PVI portion.

Yep, that's one of the key distinguishing features between top EPs and average EPs. Doing only a PVI without searching for other sources of afib can get you pretty good results on an index ablation with new paroxysmal afibbers, but patients who've been dealing with afib for years and definitely persistent afibbers will almost always have secondary sources of afib outside the PVI area.

I had a Pulsed Field Ablation in October 2024. My 6th ablation(!).

It was great to get home the same day instead of staying overnight, but overall, I'm not impressed. It hasn't stopped the AFib.

In some ways, maybe there has been improvement, in that episodes aren't as intense, but I think that's largely because of all the hard work I've done to release old stress/trauma from my nervous system and understand nervous system regulation and how to get there.

But I cannot recall my heart ever being so easily triggered. That is the greatest frustration.

Also, I found the blanking period to be rough. I have a sensitive nervous system and wouldn't be surprised if the electrical aspect just hit me harder somehow. Don't know. All I know is that I can go maybe 2 weeks with no AFib and then if there is some stressor, I can get stuck in a cycle, like now, of having an episode every day over a few weeks. Maybe 2-3 hours long.

I was diagnosed in 2013. RF ablation #1 - worked! 3 years free of AF.

Then AF recurred in 2017. RF #2 - didn't work.

FIRM ablation #3 - by the guy who invented it. Didn't work. I could write a book on that.

Hybrid ablation #4 - worked for like 1.5 yrs - till my insurance kicked me out, no warning, no possibility to consult with my EP. Traumatizing, all in all, no surprise that it totally screwed up my heart.

UCSF for RF #5 Aug 2023- didn't work

PFA #6 in Oct 2024 - didn't work

Hi Nella, welcome to the "6" club. Sorry to see you here. If you haven't already read this, you need to.

Also, FIRM is nonsense, borderline scam at this point. Sorry to say I let someone do that crap to me too but it was 2015 and it seemed like a new and promising theory. For someone to still be practicing that after 2017 is appalling. There's zero credible evidence the underlying theory has any merit and zero credible evidence that it works in practice.

Quote
Carey
PFA's main claim to fame is improved safety, not improved efficacy.

I recently had a zoom appointment with a well known experienced NY EP. He was the head of one of the trials. I asked him since PFA seems to be safer, would he ablate my LV using PFA? His reply was no because they simply are not as experienced with PFA ventricular ablations.

My PVCs are now around 50% burden (according to George’s estimate) and I’m not well enough to fly back to the states to have him perform the ablation. My three cancer surgeries have not healed and I’m instructed to remain in bed. I’m more symptomatic than ever. I took a taxi to see a doctor today and I’m wasted from an one hour drive . An 11 hour flight to NY is brutal when in PVCs and hypoxia..even with a bed onboard.

I’m hoping for a miracle. I started a new drug today in hopes to stop my PVCs and am hoping to bite the bullet from having an ablation or at least buy me some time until PFA is used more frequently with ventricular ablations without increasing my heart failure.

Have you discussed using the drug Ranolazine? There are articles in the forum that discuss use for PAC/PVC. It is an off-label use. It seems to help AFIB episodes and also Ectopic beats. Here are some articles:

[academic.oup.com]

[pmc.ncbi.nlm.nih.gov]

Also, Dr Gupta from the UK has a utube discussion about this drug for the off-label use.

Quote
Carey

the skill and experience of the practitioner, is what counts most if you're looking for successful ablations.

I think that statement is 100% correct and it remains correct if you change "ablations" to any other medical procedure. All the top EPs are using PFA now but they're mostly all still using RF too because PFA can't address every area of the heart and top EPs do more than just a PVI.

Right. Dr Reddy from NY said they don’t use PFA for ventricular ablations (PVCs) only because nobody has the volume experience yet.