The Future of PFA
Thus far, published data has shown that PFA creates effective and
durable lesions with a favorable safety profile that spares nerves,
vasculature, and the esophagus. However, there are still many unknowns,
and our understanding of electroporation biophysics continues to grow.
Future work is needed to understand how pulse waveform parameters,
electrode shape, polarity, and contact force impact myocardial lesion
formation. Better understanding of these variables may allow the
operator to titrate PFA energy to a desired lesion shape while limiting
the risk of arcing. Furthermore, it is not clear if the irreversible
electroporation threshold for the conduction system is different from
myocardium. Understanding the reversible and irreversible
electroporation thresholds for different myocardial tissues would be
useful for delivering test lesions. The future of PFA is promising, yet
it is important that we have a solid fundamental understanding of the
biophysics before it becomes universally adopted as the next ablative
energy, as “a matter that becomes clear ceases to concern us.” –
Friedrich Nietzche. A standardized way to report electrical pulse
waveforms is eagerly awaited/needed so that different PFA strategies can
be compared.