Pulsed-Field Ablation in Atrial Fibrillation: A Paradigm Shift in Electrophysiology

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and remains a leading cause of stroke, heart failure, and mortality. Catheter-based ablation, primarily pulmonary vein isolation, has become a cornerstone of rhythm control, but conventional thermal approaches carry risks of collateral injury and variable long-term efficacy. Pulsed-field ablation (PFA), a nonthermal modality that employs irreversible electroporation to selectively ablate myocardial tissue while sparing adjacent structures, has emerged as a promising alternative. This review synthesizes evidence from preclinical studies, pivotal randomized trials, and real-world registries, highlighting PFA's consistent procedural efficiency, high acute success, and favorable safety profile compared with radiofrequency and cryoablation. Catheter innovations-including balloon, circular, and lattice platforms-along with integration into electroanatomical mapping systems, have streamlined workflows and shortened procedure times. Expanding applications in heart failure, redo ablation, atrial flutter, and early ventricular tachycardia ablation underscore its versatility, while integration with artificial intelligence, high-resolution mapping, and multimodality imaging positions PFA within the future of precision electrophysiology. Nonetheless, challenges remain regarding mechanistic understanding, lesion durability, device heterogeneity, and long-term outcomes. As ongoing trials and registries mature, PFA is poised to redefine the ablation landscape and inform future guideline recommendations.