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2020 AF Symposium Abstract

Pulsed Field Ablation vs RF Ablation: a Study in Swine

by Steve S. Ryan

Background: Pulsed Field Ablation (PFA) is a new treatment for Atrial Fibrillation, but it will probably take 3-5 years to be available for most A-Fib patients.

At this year’s AF Symposium, Dr. Jacob Koruth and others from Mount Sinai Medical Center in New York City presented an abstract and poster session of an ingenious study. They conducted research on pigs to compare Pulsed Field Ablation (PFA) with Radio-Frequency (RF) ablation.

Jacob Koruth, MD

Potential Atrial Esophageal Fistula

Normally when doctors perform a catheter ablation which affects the posterior wall of the left atrium, they do everything they can to make sure they don’t also damage the esophagus which often lies just behind the posterior wall.

In a worst case scenario, damage to the esophagus can produce an atrial esophageal fistula (a hole from the esophagus into the left atrium) which can be fatal. To learn more, see 2018 AF Symposium Live Case: The DV8 Esophageal Retractor.

Moving the Esophagus to Purposefully Cause Fistula!

RF ablation vs PFA and risk of esophagus damage

Dr. Koruth and his colleagues wanted to observe was the risk of esophagus damage during a Pulsed Field Ablation (PFA) versus RF ablation. Because PFA is “tissue-specific”, they wanted to test if surrounding non-heart tissue (the esophagus) would be affected.

The subjects in this study were swine (pigs) that could be examined (dissected) afterwards.

During a normal ablation, doctors move the esophagus as far away as possible from where they are ablating.

In this study, Dr. Koruth and his team used the balloon esophageal deviation device (Manual Surgical Sciences Inc.) in all swine to purposefully move the esophagus as close as possible to the posterior left atrium wall.

They then ablated one group of swine using PFA and the other group with RF energy.

Results: Dissection of the Surrounding Non-Heart Tissue

After 25 days, dissection of the pigs revealed the following results.

The pigs who had the Pulsed Field Ablation suffered no esophageal injury damage. Whereas all the RF ablated swine suffered major esophageal injury (including one fistula).

All RF ablated pigs had major ulcerations. In comparison, none of the PFA pigs had any esophageal lesions.

Photos of Dissection: If you want to see the dissection photos comparing the tissue from the PFA vs RF ablation pigs, click on the tab below.

Dissection photos of PFA and RF ablations on swine

Views of esophageal changes at sacrifice 25 days post ablation. A: After pulsed field ablation (PFA), representative images demonstrating the normal luminal (interior) and adventitial (outer) surface of the esophagus. B: After RF ablation, a perforating ulcer and fistula is seen on the luminal (interior) part of the esophagus.

Close-up views of tissue dissected after RF ablation. A: Shows ulceration (top arrow) and perforation (center arrow) from RF ablation. B and C show partially healed ulcerations/lesions from RF ablation.

Editor’s Comments:

These Pulsed Field Ablation results are possible because PFA is “tissue-specific” and doesn’t affect surrounding non-heart tissue (such as the esophagus). It’s an incredible improvement in the treatment of A-Fib.

Pulsed Field Ablation (PFA) will eliminate the most dreaded complication of catheter ablation―Atrial Esophageal Fistula (heat damage to the esophageal from the catheter). Though a very rare complication (around 1 in 2000 cases), it’s unique in that it can kill you or result in major health problems in those who survive.

With PFA, patients and their EPs performing catheter ablations will no longer have to worry about creating these lethal Fistulas. This may be the most significant feature of PFA for Atrial Fibrillation.

It would be hard to imagine a more convincing demonstration! Kudos to Dr. Koruth and his colleagues for this study.

Reference for this article

Koruth, Jacob et al. Pulsed Field Ablation vs Radiofrequency Ablation: Esophageal Effects in a Novel Preclinical Model, Abstract AFS2020-51 p51. AF Symposium 2020 digest publication.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020