A Review of Potential Complications of Pulsed Field Ablation for AF: Beneath the Surface

Pulsed field ablation (PFA) for AF has changed the landscape of AF treatment globally. While clinical trial data have shown non-inferiority compared with thermal ablation, the safety profile of this technology is still being understood. Large post-approval registry data are now accumulating and have invariably demonstrated that rather than PFA being necessarily safer than conventional thermal ablation, the safety profile is simply different. Pericardial tamponade remains a risk and may even be greater compared with thermal ablation. Coronary artery spasm has been recognised, particularly with off-label use of PFA. Haemolysis and associated acute kidney injury are unique complications related to PFA. Stroke risk persists with likely multiple causes. Other complications, such as femoral venous injury, vagal responses and transient phrenic nerve injury, are increasingly recognised. In this review, we summarise recent data regarding potential complications associated with PFA, including mechanisms, risk factors, management and prevention.