Controversy: pulsed field ablation is the standard technique for all the candidates for atrial fibrillation ablation

Abstract

Pulsed field ablation (PFA) represents one of the most significant technological advances in atrial fibrillation (AF) therapy in recent decades. By harnessing irreversible electroporation, PFA produces myocardial lesions within milliseconds, enabling rapid and efficient pulmonary vein (PV) isolation. Early clinical experience from pivotal investigational device exemption (IDE) trials has shown acute and one-year arrhythmia-free outcomes that are non-inferior to conventional radiofrequency (RF) and cryothermal ablation. The large MANIFEST-17 K registry, encompassing over 17 000 patients treated with the Farawave system, reported an exceptionally low 0.98% major complication rate with no atrio-oesophageal fistula, phrenic nerve injury, or PV stenosis. These findings have accelerated PFA adoption across many centres. However, as experience broadens, nuances in lesion formation and durability are becoming evident. Factors such as contact force, catheter rotation, pulse train configuration, and target tissue geometry influence lesion depth and transmurality. While PV isolation appears consistently durable, data remain limited for non-PV targets such as the posterior wall, mitral isthmus, and cavotricuspid isthmus. Moreover, novel PFA-specific complications including transient left atrial dysfunction, haemolysis, and coronary artery spasm warrant ongoing vigilance. PFA has undoubtedly transformed expectations for procedural safety and efficiency. Yet whether it should already be considered the standard technique for all AF ablation candidates remains an open question. This Controversy piece explores the balance between innovation and evidence, examining whether PFA's rapid rise represents the inevitable new standard or a technology still undergoing critical refinement.