ReviewFrontiers in cardiovascular medicine2026
Complications of pulsed-field ablation for atrial fibrillation: a narrative structured review.
Review in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Authors and funding
3 authors.
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Abstract
Pulsed-field ablation (PFA) has been adopted at remarkable speed as a non-thermal approach for pulmonary vein isolation in atrial fibrillation (AF). Its mechanism-irreversible electroporation-preferentially injures cardiomyocytes while theoretically sparing adjacent heat-sensitive structures. Landmark randomised trial data (ADVENT) and large prospective registries (MANIFEST-17K; MANIFEST-PF) confirm that PFA is non-inferior to conventional thermal ablation for arrhythmia freedom and carries an overall favourable safety profile, with particularly low rates of atrooesophageal fistula and pulmonary vein stenosis. Nonetheless, substituting electrical for thermal energy introduces a qualitatively distinct injury spectrum. Intravascular haemolysis, acute kidney injury, transient coronary vasospasm, phrenic nerve stimulation, silent cerebral emboli, and-importantly-the risk of ventricular fibrillation during unsynchronised pulse delivery have each been documented across prospective cohorts and multicentre registries. This review provides a narrative structured synthesis of mechanistic and clinical evidence for each PFA-associated complication, proposes a three-tier classification (PFA-specific, PFA-enriched, and general ablation-related), and outlines practical risk-mitigation strategies. Recognition that "non-thermal" does not equate to "risk-free" is essential as PFA transitions to standard of care.
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