Advancing Atrial Fibrillation Management at the UPMC Heart and Vascular Institute: Pulsed Field Ablation

At the UPMC Heart and Vascular Institute, Chinmay Patel, MD, and colleagues are implementing the use of pulsed field ablation (PFA) into clinical practice for patients with paroxysmal atrial fibrillation (AF). Dr. Patel, who is the director of Electrophysiology at the UPMC Heart and Vascular Institute in Central Pa, has participated as a principal investigator in multiple multicenter trials evaluating PFA, including the pivotal Pulsed Field Ablation to Treat Atrial Fibrillation (ADVENT) trial, the Advantage AF phase I and II trials, and ongoing post-approval and long-term outcomes studies. Since the U.S. Food and Drug Administration (FDA) approved Boston Scientific's Farapulse™ system in March 2024, the UPMC Heart and Vascular Institute has been using the new catheter-based approach routinely beginning in October 2024.

The ADVENT study was the first randomized clinical trial to directly compare the efficacy and safety of the FARAPULSE PFA System against standard-of-care thermal ablation.

The ADVENT study was conducted at 30 medical centers with patients randomized to be treated with PFA or thermal ablation. Results of the ADVENT trial showed that AF ablation performed using Farapulse PFA system is as effective and safe as conventional thermal ablation. The UPMC Heart and Vascular Institute in Central Pa. was one of the top enrolling sites in the ADVENT trial, the first center in Pennsylvania and third in the country with 50 patients treated by Dr. Patel.

"Pulsed field ablation is now becoming preferred modality for ablation of atrial fibrillation," says Dr. Patel. “The method offers several clinical benefits for well-selected patients over our other current ablation modalities, including cryo- and thermal ablation approaches.

Mechanism and Benefits of PFA

PFA uses microsecond bursts of high-voltage direct current to ablate cardiac tissue through irreversible electroporation, a process that disrupts the integrity of the cell membrane leading to irreversible cell death.  PFA is able to selectively affect myocardial cells while sparing neighboring tissues such as the esophagus and phrenic nerve from off-target effects.

"Every tissue has its own threshold for electroporation," says Dr. Patel. "Cardiac cells are more sensitive than nerve or esophageal cells, so this ablation technique allows for a more targeted approach that spares other tissues from damage.”

In addition to the improved safety profile, PFA offers several procedural advantages. Procedure times tend to be shorter than with thermal ablation, and many patients can undergo the procedure under moderate sedation rather than general anesthesia. 

Clinical Indications and Patient Selection

The Farapulse system is currently approved for use in patients with paroxysmal AF. However, ongoing clinical trials, including the Advantage AF study, are evaluating the use of Farapulse and PFA in patients with persistent forms of AF.

“Any patient with symptomatic drug refractory atrial fibrillation — or atrial fibrillation that contributes to heart failure — is a potential candidate for ablation,” says Dr. Patel. 

A single episode of AF that resolves spontaneously does not typically warrant consideration for ablation. The decision depends more on recurrence, high symptom burden, and the patient’s response to first-line medical therapies. Recurrent AF that persists despite treatment with rate control medications like metoprolol often leads to consideration of rhythm control strategies, with ablation being viewed more as a preferable first-line intervention over antiarrhythmic drugs as the evidence base continues to build.

“The thinking has shifted,” says Dr. Patel. “There is a growing emphasis on rhythm control for a broader range of patients, even those who are asymptomatic, because we now know it reduces stroke risk and heart failure hospitalizations.”

This approach is informed by a larger strategy to maintain sinus rhythm early and more consistently in the course of the disease, with ablation offered sooner in the treatment algorithm when patients fail to maintain rhythm on first-line medications.

"Medications for rhythm control are generally not as effective as ablation," says Dr. Patel. "If someone has recurrent AF despite treatment with basic medications like metoprolol or Cardizem, they should be evaluated for ablation. Keeping the AF in remission and reducing the risk of thromboembolic stroke and heart failure are our main missions when dealing with AF."

Postprocedural Care and Anticoagulation

Postprocedural care following PFA is largely similar to other forms of AF ablation. Patients remain on their preprocedural medications for at least three months before being evaluated for discontinuation. Antiarrhythmic medications may be discontinued after that point, depending on their heart rhythm stability and other factors

"Blood thinners are continued for three months after ablation, regardless of outcome," says Dr. Patel.

"Longer-term use depends on their stroke risk, which we assess using the CHA2DS2-VASc score, not on whether the ablation was successful. Ablation techniques don’t ‘cure’ AF but instead help us achieve long-term remission and symptom control and prevent the worst complications from the condition – namely stroke and heart failure.”

AF Referral Guidance 

Dr. Patel encourages early recognition and semi-urgent referral of patients with AF. His advice for primary care physicians is to start anticoagulation when appropriate and refer patients to cardiology within a month of diagnosis.

"The days of letting patients remain in AF while controlling heart rate with medication alone are behind us," says Dr. Patel. "Maintaining sinus rhythm has clear benefits. Cardiologists can evaluate whether cardioversion is appropriate, and an electrophysiologist can determine if ablation should follow."