JACC Clin Electrophysiol. 2026 Jun 8:S2405-500X(26)00449-4. doi: 10.1016/j.jacep.2026.04.031. Online ahead of print.
ABSTRACT
BACKGROUND: Pulsed field ablation (PFA) is an increasingly used energy source to treat patients with atrial fibrillation (AF). Although nonthermal ablation seems to result in a safety benefit, adverse events occurring after PFA are not well studied.
OBJECTIVES: The aim of this study was to report life-threatening ischemic and arrhythmic adverse events (AEs) occurring after PFA of AF.
METHODS: A case series and systematic literature review were conducted, including patients with AF who experienced ischemic AEs with delayed onset or arrhythmic AEs after PFA energy delivery between March 2023 and January 2026. Events were classified as 1) delayed and/or recurrent ST-segment elevation; 2) ventricular arrhythmia (VA); or (3) sudden cardiac death.
RESULTS: A total of 39 patients (30 from literature review and 9 newly published extended case series [9 of 5,963 procedures (0.15%)]) were included (mean age 67 ± 10 years, 72% men, 72% with persistent AF, 51% with coronary artery disease). Seventeen patients presented with delayed ST-segment elevation at a median of 16 minutes (Q1-Q3: 4-315 minutes) after last PF delivery, of whom 11 (65%) subsequently developed VA and 2 died (12%). Among the 13 patients with available 12-lead electrocardiograms, ST-segment elevation was observed in the inferior leads (n = 10 [77%]), anteroseptal leads (n = 1 [8%]), or both (n = 2 [15%]). VA occurred in another 6 patients and sudden cardiac death in 16 patients at a median of 6 days (Q1-Q3: 2-18 days) after PFA.
CONCLUSIONS: Rare but life-threatening ischemic and malignant arrhythmic AEs associated with PFA underscore the need for structured surveillance and standardized reporting. A deeper understanding of the underlying mechanisms will be essential to identify patients at risk and guide future studies aimed at further improving the safety of PFA.
PMID:42283658 | DOI:10.1016/j.jacep.2026.04.031