Addressing Air Intrusion in Pulsed Field Ablation Sheaths: A Step Toward Safer Ablation Procedures

Balancing Efficiency and Outcomes in the Evolution of Catheter AblationIbrahim Hasan MD, Marwan M. Refaat MDDepartment of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, LebanonRunning Title: Balancing Efficiency and Outcomes in AblationWords: 696 (excluding the title page and references)Keywords: Catheter Ablation, Cardiovascular Diseases, Cardiac ArrhythmiasFunding: NoneDisclosures: NoneCorrespondence:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPTenured Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonFax: +961-1-370814Clinic: +961-1-759616 or +961-1-355500 or +961-1-350000/+961-1-374374 Extension 5800Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Email: mr48@aub.edu.lbThe recent review “Catheter Ablation: Evolution and Efficiencies” offers a timely and insightful synthesis of the historical evolution, current practice, and procedural imperatives surrounding catheter ablation in electrophysiology (EP) [1]. As catheter-based interventions increasingly define the standard of care for arrhythmias—including atrial fibrillation, atrial flutter, supraventricular tachycardia, and ventricular tachycardias—understanding procedural efficiency has never been more critical. The review excels in contextualizing the historical progression of catheter ablation technologies, from initial direct current ablation to radiofrequency ablation (RF), cryoballoon, and the emerging pulsed field ablation (PFA). By tracing technical evolution alongside procedural adaptations, the authors illustrate how efficiency has been both a driver and a product of technological advancement. For instance, novel irrigated-tip RF catheters and contact force–sensing technologies have allowed for shorter procedure times and better ablation outcomes respectively [2], demonstrating the interplay of efficiency and efficacy. Moreover, PFA offers single-shot approaches [3], and it significantly reduced procedure time while maintaining high rates of pulmonary vein isolation as shown in multiple trials [4]. The review methodically addresses practical strategies to optimize EP lab efficiency. Ultrasound-guided femoral access, for example, is emphasized as a method to reduce the vascular complications and puncture time [5]. Anesthesia considerations are also thoughtfully discussed, highlighting that general anesthesia can decrease procedure times and improve ablation efficacy without compromising safety [6], while moderate sedation may remain sufficient for less complex arrhythmias. Invasive hemodynamic monitoring is addressed, with the authors recommending selective use of arterial lines for patients with impaired cardiac function or high procedural complexity, reflecting a balance between procedural oversight and resource utilization, as shown in a multi-center study that catheter ablation for atrial fibrillation can be safely conducted without reliance on invasive hemodynamic monitoring [7].The review also provides a detailed discussion of catheter selection and mapping strategies. High-density and omnipolar mapping techniques have been shown to reduce procedure time and enhance ablation accuracy, thereby improving both efficiency and outcomes [8, 9]. Of particular interest is the emerging role of PFA, which uses irreversible electroporation to rapidly create myocardial lesions while minimizing collateral tissue injury [3]. Studies report acute pulmonary vein isolation rates reaching 100%, with procedure times averaging under 100 minutes and low complication rates [10, 11]. The integration of PFA with three-dimensional mapping systems further consolidates mapping and ablation into a single workflow, exemplifying the potential for procedural streamlining without compromising patient safety [12].Despite its strengths, the review has some limitations. While procedural efficiency is emphasized, economic analyses are limited. Cost-effectiveness, total resource utilization, and comparative expenditures across different ablation modalities are important considerations that are only partially addressed, as a recent study found that while PFA had shorter procedure times compared to cryoballoon ablation and RF ablation, it was significantly more costly [13]. Finally, the review briefly acknowledges operator experience and learning curves, but high-volume centers consistently demonstrate superior outcomes [14], and structured training programs will be critical for the safe adoption of novel technologies.Building on the foundation established in the review, several avenues for future research emerge. Detailed economic and resource utilization analyses across different healthcare settings would provide valuable guidance for sustainable implementation of advanced ablation technologies. Multicenter registry data can clarify the translation of efficiency gains into real-world outcomes and inform best practices for training and standardization. Risk stratification models that integrate patient characteristics, procedural parameters, and device selection could further optimize outcomes while maintaining high efficiency. Finally, the integration of artificial intelligence in mapping, catheter navigation, and lesion assessment may represents a promising frontier for standardizing procedural efficiency and enhancing patient safety.In conclusion, the review provides a comprehensive, timely, and practical synthesis of a rapidly evolving field. By framing efficiency as a balance between procedural speed, safety, and efficacy, the review offers actionable guidance for clinicians navigating increasingly complex EP interventions. Its integration of historical context, technical evolution, and emerging technologies underscores the transformative potential of innovation in enhancing patient outcomes. Nonetheless, systematic evaluation of safety, cost-effectiveness, and long-term outcomes remains essential to ensure that efficiency gains translate into meaningful clinical benefit. Future research focused on comparative effectiveness, patient-centered outcomes, and AI-driven procedural optimization will be key to advancing the field of electrophysiology while maintaining high-quality care.

Pulsed Field Ablation Systems for Atrial FibrillationIbrahim Hasan MD, Marwan M. Refaat, MDDivision of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, LebanonRunning Title: PFA Systems for AFWords: 568 (excluding the title page and references)Keywords: Ablation, Pulsed Field, Atrial Fibrillation, cardiac arrhythmias, cardiology, cardiovascular diseasesFunding: NoneDisclosures: NoneCorresponding Author:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPTenured Professor of MedicineTenured Professor of Biochemistry and Molecular GeneticsMember, Division of Cardiology/ Section of Cardiac ElectrophysiologyDirector, Cardiovascular Fellowship ProgramAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonUS Address: 3 Dag Hammarskjold Plaza, 8th Floor, New York, NY 10017, USAOffice: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)The field of atrial fibrillation (AF) ablation is witnessing a transformative shift with the pulsed field ablation (PFA) technologies. PFA, a non-thermal energy source that selectively targets myocardial tissue while sparing adjacent structures such as the esophagus and phrenic nerve, holds promise in addressing the limitations of conventional thermal ablation techniques. The recent multicenter registry study comparing the FARAPULSE™ pentaspline catheter and the PulseSelect™ circular catheter provides valuable real-world data on procedural characteristics, acute efficacy, and safety of these commercially available PFA systems.This registry, encompassing over 400 patients from six international centers, demonstrated 100% acute pulmonary vein isolation (PVI) success in both cohorts, confirming the robust efficacy of PFA in AF ablation. Notably, procedural times were significantly shorter with the pentaspline catheter (median 36.0 minutes) compared to the circular catheter (median 49.0 minutes, p < 0.001). These findings align with earlier studies, such as the ADVENT trial [1], and a meta-analysis by Aldaas et al [2], which highlighted the procedural efficiency of PFA over traditional thermal ablation techniques. The shorter procedure times observed with the pentaspline catheter may reflect its design optimized for rapid and efficient PVI, though operator experience and workflow factors likely contribute as well. Both systems exhibited low rates of major adverse events, with only 0.5% of patients experiencing a stroke and 0.2% suffering a serious vascular complication. Importantly, minor vascular access site complications were more frequent in the pentaspline group (11.9% vs. 1.1%, p < 0.001), underscoring the need for meticulous vascular access techniques in PFA procedures.The authors appropriately acknowledge several limitations inherent to the study’s observational, non-randomized design. Missing data, potential underreporting of adverse events, and variations in operator experience and institutional protocols across centers could influence outcomes. While most patients underwent standardized post-procedural monitoring and at least one follow-up visit, the possibility of undetected events cannot be fully excluded. Selection bias, although minimized by system availability, remains a potential confounder. Importantly, the study reports only acute procedural outcomes, leaving long-term efficacy, lesion durability, and arrhythmia recurrence unaddressed. While prior studies, including the PULSED AF pivotal trial [3] and data from the MANIFEST-PF Registry [4], suggest promising long-term outcomes for PFA comparable to thermal ablation, randomized controlled trials comparing different PFA systems over extended follow-up periods are needed to establish their relative benefits.This study represents the first head-to-head, multicenter comparison of two commercially available PFA systems in a real-world setting. Despite procedural differences, both systems achieved excellent acute outcomes with low complication rates. The multicenter design, while introducing heterogeneity, enhances the generalizability of findings and provides a broader perspective on current clinical practice. Looking ahead, several critical questions remain: Will the procedural efficiency advantages of the pentaspline catheter translate into meaningful improvements in long-term arrhythmia-free survival? Can the lower incidence of vascular complications with the circular catheter be maintained in larger, diverse patient populations? Moreover, as PFA technology evolves, how will novel catheter designs, lesion assessment tools, and mapping strategies influence clinical outcomes?The findings of this comparative registry study reinforce the safety and efficacy of PFA as an emerging standard for AF ablation. Both the FARAPULSE™ and PulseSelect™ systems demonstrate high procedural success and low major adverse event rates, though procedural characteristics and minor complication profiles differ. Further research—particularly prospective, randomized trials with long-term follow-up—will be critical to define the optimal role of each PFA system and solidify PFA’s position in the therapeutic armamentarium for atrial fibrillation.