Electroporation has been used to treat non-cardiovascular conditions, including solid tumors. Supported by beneficial safety and efficacy data from randomized clinical trials, pulsed-field ablation (PFA) is now emerging in clinical practice to treat heart rhythm disorders, including atrial fibrillation (AFib). Duke began offering PFA in March 2024 and performed over 100 procedures in the first eight months.

“While the success rate is similar to traditional thermal ablation, PFA enables more efficient procedures with lower risk of severe complications. Patients undergoing PFA also appear to have a gentler recovery,” says Jonathan P. Piccini Sr., MD, MHSc, electrophysiologist and director of cardiac electrophysiology at Duke Heart.

Catheter ablation is recommended as a first-line therapy for persons with symptomatic AFib despite medical therapy, select persons with intermittent AFib, and those with heart failure and a reduced ejection fraction.

Previously, only thermal technologies — radiofrequency ablation, laser balloon ablation, and cryoablation — were available. Now FDA approved, PFA offers a more efficient, reproducible, and tissue-selective option to limit damage to other structures such as the esophagus or phrenic nerve. Complications such as esophageal fistulae, pulmonary vein stenosis, and pericarditis are also less frequent with PFA.

PFA is typically faster than thermal procedures, requiring less time under anesthesia and on mechanical ventilation. “We’re also examining national data on how patients do after PFA. Some early data suggest patients treated with PFA may have lower health care utilization following the procedure,” Piccini says.

Selecting which patients are best suited for PFA is complicated, Piccini says: “In general, we particularly favor PFA for first-time ablation recipients, but it depends on each patient’s unique circumstances and history.”

Each PFA system works slightly differently, and having multiple technologies allows providers to tailor treatments to each patient. “At Duke, we have all the approved PFA technologies and look forward to acquiring future technologies as soon as they’re approved,” Piccini continues. With a high volume of ablations annually, many heart rhythm clinicians dedicated to complex ablations, and a large research program, Duke is dedicated to improving outcomes for patients with AFib.

“Over the past 20 years, we’ve seen dramatic improvements in therapies to treat AFib, and PFA is only the most recent. It’s very safe, and major adverse events are relatively rare,” says Piccini. “If you have a patient with AFib that’s bothersome and symptomatic, or with AFib and heart failure, they should be referred to an electrophysiologist, preferably at a high-volume center like Duke, to discuss rhythm control strategies.”