Pulsed field ablation: Biophysical principles and practical considerations in atrial fibrillation treatment

Pulsed field ablation (PFA) is an emerging nonthermal ablation modality for the treatment of atrial fibrillation. Unlike conventional thermal energy sources such as radiofrequency and cryoablation, PFA delivers high-voltage pulsed electric fields that induce irreversible electroporation, resulting in selective cardiomyocyte death while largely preserving surrounding extracellular structures. The biological response to pulsed electric fields depends on parameters such as field strength, pulse duration, waveform configuration, and number of pulses. Variations in electroporation thresholds among different cell types contribute to the relative myocardial selectivity observed with PFA. Lesion formation is also influenced by electrode configuration, catheter-tissue contact, and electric field distribution. Early clinical experience and large registries suggest that PFA enables efficient pulmonary vein isolation with a favorable safety profile and reduced risk of collateral injury compared with thermal ablation technologies. This review summarizes the fundamental biophysical mechanisms underlying pulsed electric field ablation and discusses practical considerations for its clinical application in atrial fibrillation ablation.