Q&A: What cardiologists know and don’t know about pulsed field ablation
Cardiac ablation is one of the most important procedures in modern healthcare, allowing electrophysiologists to target irregular heart rhythms with precision and accuracy.
Ablation technology has experienced a breakthrough in recent years thanks to the development and implementation of pulsed field ablation (PFA). PFA uses high-voltage electrical pulses to treat paroxysmal and persistent atrial fibrillation (AFib) as opposed to the heat and cold used by radiofrequency (RF) ablation and cryoablation, respectively. It is consistently linked to positive patient outcomes and a superior safety profile, and cardiologists are increasingly turning to PFA as a go-to treatment option.
So what does the future of cardiac ablation look like as PFA continues to gain momentum? Cardiovascular Business turned to cardiologist Peter Weiss, MD, to find out. Weiss is a veteran electrophysiologist with Banner – University Medical Center Phoenix and director of the Cardiovascular Intervention Center at the Banner – University Medicine Heart Institute. He has been tracking the evolution of this technology for many years, keeping a close eye on the latest clinical research and the ever-changing electrophysiology (EP) market.
Weiss participated in a panel about cardiac ablation during HRX 2025, an annual electrophysiology conference hosted by the Heart Rhythm Society. He also sat down with Cardiovascular Business for an in-person interview during the show.
Read below for the full conversation:
Cardiovascular Business: One of the hottest topics in electrophysiology right now is the steady rise of PFA. What is your take on where things stand today with this popular technology?
Peter Weiss, MD: There is an incredible focus right now on PFA—is it a true paradigm shift or is this all some sort of mass hysteria? Right now, I think maybe it is a little bit of both. There are clear benefits for patients, and we’re all hopeful about PFA, but it is still very early.
One thing worth noting is that the outcomes remain about the same as they were with other ablation technologies for the treatment of AFib—no matter what you use, PFA or one of the existing ablation techniques, we’re still maxing out at a success rate of about 70% at one year of follow up.
As time goes on, it is important to remember that PFA is very different from RF and cryoablation. RF devices are always roughly the same, and cryoablation devices are always roughly the same, but every PFA device is different. The form factors are different, the wave forms are different, how they’re delivered is different—there are many more variables than we have had in the past. It will be interesting to see how this all evolves.
Another thing to watch in the EP community is that we need to make sure we are still always doing what is best for our patients. We don’t want to get pulled too far toward becoming factories for pulmonary vein isolation. We do have a lot of patients to take care of, but we also need to continue to be really good doctors and good healthcare providers.
With PFA, for example, it seems to lead to faster procedures and it may increase patient safety—but are we sure it is not creating new problems? It is true we will not be up all night worrying about esophageal perforations, but do we now need to worry about hemolysis? What about brain lesions? I just think we will probably have some tamping down of enthusiasm as we start to explore more of those things.
How concerned are you about the potential side effects of PFA? Phrenic nerve damage, for example, is starting to gain attention as something to keep a close eye on.
With any new technology, you start to learn more about it as gets used in the wild on a larger number of patients. I think that’s what we’re seeing right now; you’re starting to see things come up that we did not see in the early studies.
It’s a fantasy to think we will have a technology that is free of all side effects. But having rigorous post-marketing studies and registries—and maybe having reimbursement dependent on registry participation—can help us learn more in this post-marketing world.
"With any new technology, you start to learn more about it as gets used in the wild on a larger number of patients. I think that’s what we’re seeing right now; you’re starting to see things come up that we did not see in the early studies."
Peter Weiss, MD, Director of the Cardiovascular Intervention Center at the Banner – University Medicine Heart Institute
As far as phrenic nerve damage goes—that’s a relatively new one with PFA. I think a lot of it is probably just stunning during recovery and there will be very few patients with long-term phrenic nerve issues. But it is important to recognize that PFA is not completely free of this issue.
And we have not yet seen esophageal injuries with PFA—knock on wood—but could that potentially change if we start talking about much higher voltages, for example? These are all things to consider.
Will another new ablation technique make a big impact in the near future?
Anything new is going to have a pretty tough uphill climb against the current climate of PFA. The speed, the effectiveness, the potential safety benefits—these things all make PFA a pretty tough train to turn around.
I think we are going to see more and more PFA in the future. There is so much momentum in that directly, and large medtech companies have already invested millions of dollars in PFA—they are not going to want to stop and go in an entirely new direction.
What else stands out when you think about the current state of cardiac ablation?
I think we need to be smarter about how we do this. I don’t know that the answer in the long run is going to be these huge form factors that just crush everything. There will be a place for some of that, but really we need to better understand the underlying substrate and focus on ablation lesions in a more meaningful way. I do a lot of work in ventricular ablation, and these things are a little clearer there—it has helped us achieve great outcomes. We just really need to get better at understanding what we are ablating and why.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.