Safety profile of pulsed field ablation regarding phrenic nerve function

We read with great interest the comprehensive review by Sugrue and colleagues.1 Pulsed field ablation (PFA) is a promising, nonthermal energy allowing efficient pulmonary vein isolation during atrial fibrillation catheter ablation. However, uncertainties persist regarding the impact of PFA on right phrenic nerve (PN) function, with a subsequent risk of PN stunning (ie, transient) or palsy (ie, persistent). Indeed, data from the recently published MANIFEST-17K (Multi-National Survey on the Safety of the Post-Approval Clinical Use of Pulsed Field Ablation in 17,000+ Patients) registry found a low incidence (0.06%) of PN palsy,2 but such a complication might have been overlooked by the retrospective design of the study and the absence of systematic PN function monitoring during PFA procedures.