INTRODUCTION
Atrial fibrillation (AF) is a common and increasingly prevalent arrhythmia, characterized by highly irregular atrial electrical activity and a loss of coordinated function, leading to disrupted ventricular filling and reduced effective pumping capacity. Globally, the prevalence of AF has reached approximately 2.5% in developed countries and is on the rise in developing nations. The risk of developing AF increases significantly with age, making it one of the most common arrhythmias in elderly patients with cardiovascular diseases[1,2].
AF is not just an electrocardiogram abnormality; it is a systemic condition that profoundly affects overall hemodynamic stability and organ perfusion. AF causes uncontrolled ventricular rates, loss of atrial mechanical function, and increased blood stasis within the atria, creating conditions conducive to thrombus formation, thereby significantly increasing the stroke risk for AF patients, which is more than five times higher than that of the general population. Additionally, AF is positively correlated with the development of heart failure, deterioration of left ventricular function, and increased mortality[3]. It also has long-term detrimental effects on the quality of life and cognitive function in elderly patients. This “multi-organ chain reaction” triggered by arrhythmia makes AF management not just about controlling heart rate or rhythm but requires a comprehensive approach to assess stroke prevention, heart function maintenance, and overall risk management[4,5].
Although the pathophysiological basis of AF has been extensively explored over the past few decades, traditional treatment strategies still face significant limitations. Pharmacological treatments (including antiarrhythmic and anticoagulant drugs) play a crucial role in symptom relief and stroke risk reduction, but their effectiveness often wanes in long-term follow-up, with issues such as drug toxicity and high recurrence rates[6]. Moreover, pharmacological treatment fails to effectively address structural atrial remodeling or fundamentally alter the disease’s natural course. For patients who do not respond to or cannot tolerate pharmacological treatment, catheter ablation has become an important intervention to restore sinus rhythm, but this technique itself presents significant challenges and risks. Traditional thermal catheter ablation methods, such as radiofrequency ablation (RFA) and cryoablation, have become routine clinical practices[7,8]. However, the mechanisms of electrical isolation through thermal injury are difficult to avoid, causing non-selective damage to adjacent structures such as the esophagus, phrenic nerve, or coronary arteries. Studies suggest that complications related to thermal ablation include thermal injury to surrounding tissues, esophageal damage, phrenic nerve injury, and even pericardial effusion. Moreover, ablation success rates and long-term maintenance of sinus rhythm remain suboptimal in patients with persistent AF[9,10].
In this context, pulsed field ablation (PFA), a novel non-thermal energy ablation technique, has emerged as a potential breakthrough to address the limitations of traditional ablation methods. Unlike thermal ablation, which relies on temperature to induce tissue necrosis, PFA uses high-voltage short electrical pulses to induce irreversible electroporation (IRE), selectively damaging myocardial cells at the tissue level while minimizing damage to surrounding non-myocardial structures[11,12]. This mechanism not only nearly eliminates the non-specific damage to adjacent tissues common in traditional techniques but also allows for more precise control over the ablation range due to its sensitivity to cell type differences. Existing preclinical and early human studies show that PFA not only maintains comparable or even superior acute ablation outcomes to thermal ablation but also significantly reduces the risk of complications, particularly offering a clear safety advantage in preventing esophageal and phrenic nerve damage[13,14].
However, despite the immense technical potential of PFA, as a relatively new ablation strategy, it still faces the challenge of insufficient evidence from evidence-based medicine. Currently, high-quality follow-up data mainly focus on paroxysmal AF and short-term outcomes at one year, while long-term efficacy, safety, and optimal energy parameters for persistent and complex structural atrial remodeling remain to be validated through larger, multi-center randomized trials[15,16]. Therefore, further exploration of the biophysical mechanisms, clinical application evidence, and perioperative care strategies for PFA is essential for advancing it as a key component in the future management of AF, with significant theoretical and clinical value[17].
In conclusion, AF, as a highly prevalent and progressive cardiovascular disease, presents significant challenges to current treatment models due to its complex pathophysiology and multiple comorbid risks. Traditional pharmacological and thermal ablation techniques still require a balance between practicality and safety, while the emergence of PFA has injected innovative momentum into the field[18,19]. This review will further discuss the mechanisms, clinical evidence, and care strategies of PFA in the subsequent chapters. Specifically, the primary aim is to evaluate the biophysical mechanisms and comparative clinical efficacy of PFA against thermal modalities. The secondary aim is to systematically analyze PFA-specific perioperative nursing interventions, such as protocols for managing unique complications like coronary vasospasm and hemolysis, to optimize holistic patient outcomes[20,21].
OVERVIEW OF PFA TECHNOLOGY
PFA represents a paradigm shift in catheter ablation techniques for AF. Its core scientific principle is the non-thermal, field-mediated IRE that causes cell membrane disruption. During the PFA process, a series of ultra-short high-voltage electrical pulses (typically in the microsecond range) are applied, instantly inducing nano-scale pores in myocardial cell membranes[22,23]. These pores are not simple thermal lesions; they result from a drastic imbalance in the membrane potential, leading to cellular homeostasis disruption, calcium ion imbalance, loss of membrane function, and programmed cell death, ultimately causing irreversible damage to the targeted tissue[24,25]. Unlike thermal ablation, which relies on temperature gradients to induce protein denaturation and cell death, PFA’s energy transfer depends more on field strength and the electrophysiological properties of cells, rather than temperature changes, thus significantly altering the biophysical basis of ablation lesions[26].
This fundamental difference in mechanism not only impacts the morphology of ablation areas but also determines the clinical safety and energy transfer efficiency of PFA. One of the most striking features of PFA is its tissue selectivity[27]. The electroporation threshold varies significantly across tissues, myocardial cells are much more sensitive to high-intensity electrical fields compared to surrounding structures such as esophageal epithelium, phrenic nerves, or endothelial cells[28]. This feature allows for the partial or complete preservation of non-target tissues while ablating myocardial lesions, significantly reducing the risk of adjacent tissue damage commonly seen in traditional thermal ablation, such as phrenic nerve paralysis, atrio-esophageal fistulas, or damage to surrounding blood vessels[29].
Secondly, compared to traditional RFA and cryoballoon ablation (CBA), which rely on thermal injury mechanisms, PFA’s energy transfer does not induce significant thermal coagulation or freezing stress responses[30]. Traditional energy sources cause damage by heating or cooling myocardial tissue, but thermal energy tends to diffuse to adjacent structures at tissue interfaces, causing uncontrollable collateral damage[31]. While cryoablation generates more uniform lesions, it requires prolonged low-temperature maintenance, which can still cause damage to surrounding tissues in complex cardiac environments. In contrast, PFA creates controlled lesions in a few milliseconds to tens of microseconds through electrical fields, with minimal reliance on temperature-induced pathological changes[32]. This represents a fundamental innovation in ablation technology by breaking the physical boundaries of thermal therapy from a biophysical perspective[33].
From a clinical implementation perspective, this non-thermal mechanism brings several significant advantages. First, lesion formation is faster. Traditional radiofrequency point-to-point ablation requires energy delivery, contact force adjustment, and cooling time for each point[34]. In contrast, PFA can cover a large area of the electrical field in a shorter time, reducing the time spent in the left atrium and overall procedure duration. Research has shown that at equivalent lesion depths, PFA creates lesions that are wider and more symmetrical. Its reduced dependence on blood flow velocity enhances the stability and reproducibility of the procedure[35].
Secondly, PFA significantly reduces the risk of specific complications. Improper thermal ablation can lead to esophageal injury, which may develop into an atrio-esophageal fistula, a rare but highly fatal complication[36]. In contrast, PFA’s electrical field ablation does not directly heat the esophagus or surrounding tissue near the pulmonary vein entrance, offering clearer safety boundaries. Studies comparing PFA with thermal ablation report lower postoperative complication rates and significantly reduced risks to the phrenic nerve and esophagus[37].
It is important to emphasize that, although PFA shows clear advantages in terms of biophysics and early clinical observations, the long-term lesion maturation process and electrical remodeling stability remain central to ongoing research. Unlike the fibrosis and other histological changes associated with thermal ablation, the tissue repair and fibrosis processes in PFA lesions may be more complex[38]. The long-term stability of these biological tissue responses requires further follow-up and histological studies to clarify. Existing reviews suggest that while PFA performs excellently in acute success rates and complication control, its lesion durability, long-term freedom from AF, and potential need for re-ablation remain key criteria for evaluating its overall clinical competency[39,40] (Figure 1).
Figure 1 The core mechanism of pulsed field ablation, which uses ultra-short, high-voltage electrical pulses to induce irreversible electroporation in myocardial cells.
The process generates nanoscale pores in the cardiomyocyte membranes, disrupting calcium homeostasis and leading to programmed cell death (irreversible electroporation). It also demonstrates the tissue selectivity of pulsed field ablation, showing its higher sensitivity in myocardial cells compared to other tissues like the esophagus and nerves, preserving non-target structures.
In conclusion, PFA technology breaks the physical limits of traditional thermal ablation through its unique IRE mechanism, enabling selective destruction of myocardial cells while maximizing protection of non-target tissues. This represents a technological revolution in the field of AF ablation. This interdisciplinary energy form not only strengthens the safety boundaries of ablation but also lays the theoretical and practical foundation for enhancing intraoperative efficiency and reducing complications. It offers a new technological path and more promising clinical solutions for the treatment of AF.
CLINICAL EVIDENCE AND CURRENT APPLICATION OF PFA IN AF TREATMENT
As PFA technology transitions from theoretical and preliminary trials to large-scale clinical practice, its efficacy and safety in treating AF have been systematically validated through multicenter, real-world, and early randomized controlled trials (RCTs). PFA is not simply an alternative energy source; it represents a technological revolution based on a unique biophysical mechanism. Its clinical evidence framework reflects an evidence-based progression from early small-sample observations to large-scale data support[41,42].
Acute success rates and long-term freedom from AF
Multiple clinical cohorts and systematic reviews consistently show that PFA achieves a very high acute success rate in pulmonary vein isolation (PVI), which is often considered the primary measure of AF ablation efficacy[43]. Early “first human” studies and subsequent case reports indicate that PFA achieves near or complete (100%) immediate success in PVI for both paroxysmal and persistent AF, with all pulmonary veins successfully electrically isolated. This high immediate success rate is closely related to its ability to form effective lesions with a single or minimal number of electrical pulses, reducing dependence on point-by-point manipulation[44].
In mid- to long-term follow-up, real-world and prospective cohort studies show that PFA maintains sinus rhythm in a significant proportion of patients over a 12-month follow-up period. For example, multicenter use of the PulseSelect™ PFA catheter in a Japanese population demonstrated safety and efficacy similar to global cohorts, with notable improvements in patients’ quality of life (ClinicalTrials.gov NCT04198701)[45]. Furthermore, the PULSE EU trial reported good results with the use of a spherical integrated PFA catheter, forming durable lesions within one year, suggesting that lesion durability is clinically acceptable in the short term[45,46].
Notably, preliminary data for persistent AF are also becoming more robust. For example, the PersAFOne study, published in Journal of the American College of Cardiology 2025, showed that PFA achieved statistically significant results in the primary efficacy endpoint for persistent AF patients at one-year follow-up (with a primary efficacy measure of over 60%). Although this result is lower than for paroxysmal AF, it shows comparable or even fewer re-ablation requirements in a more challenging patient group, indicating PFA’s potential across different AF subtypes[47,48] (Figure 2).
Figure 2 The clinical advantages of pulsed field ablation for atrial fibrillation, including high acute efficacy, enhanced safety profile, and improved procedural efficiency.
It highlights the mechanism of irreversible electroporation, the tissue selectivity in myocardial ablation, and the reduced collateral damage to surrounding tissues such as the esophagus and phrenic nerve. The figure also outlines key steps in the perioperative pathway for optimal patient outcomes. PFA: Pulsed field ablation; EF: Ejection fraction; HTN: Hypertension; LA: Left atrial; DM: Diabetes mellitus; CKD: Chronic kidney disease; DOACs: Direct oral anticoagulants; HR: Heart rate; BP: Blood pressure; SpO2: Pulse oxygen saturation; ECG: Electrocardiogram; ACT: Activated clotting time; QoL: Quality of life; AF: Atrial fibrillation.
Multicenter and real-world large-sample safety evidence
In addition to efficacy, PFA’s safety evidence is particularly noteworthy and one of the key comparison points with thermal ablation technologies. PFA achieves selective myocardial tissue ablation through IRE. This selective mechanism has been shown in both preclinical and clinical data to significantly reduce the risk of adjacent tissue damage, such as esophageal, phrenic nerve, and pulmonary vein stenosis complications, with fewer or no noticeable injuries[36,49].
Large-scale real-world data, such as the MANIFEST PF Registry, report safety and efficacy data from over 17000 AF patients undergoing PFA. The overall adverse event rate was significantly lower than historical thermal ablation data, with fewer severe complications associated with traditional techniques. This large-scale data provides crucial support for the scalability of PFA in various clinical settings[36]. Moreover, several systematic reviews and meta-analyses indicate that, with comparable acute PVI success rates, PFA shows higher first-pass isolation rates, lower short-term recurrence risks, and a trend towards fewer thermal ablation-related complications, such as phrenic nerve damage and esophageal injury[50].
It is important to emphasize that, in building a safety reputation, attention should also be paid to performance differences among various PFA systems and devices. For example, some systems reported neurovascular events in early clinical trials, highlighting the need for comprehensive evaluation based on device characteristics and operator experience (such as neurovascular event reports for the Varipulse system). This underscores the need for careful monitoring and strict protocols, even for advanced technologies, before widespread clinical application[51,52].
Comparison with traditional thermal ablation
Systematic comparisons show that, in terms of short-term and one-year efficacy measures, PFA demonstrates non-inferiority to traditional RFA or CBA, with even slight advantages in some metrics[53]. For example, some systematic reviews show that PFA, compared to thermal ablation, has a higher first-pass isolation rate, lower atrial arrhythmia recurrence, and a significantly shorter operation time. These findings suggest that PFA strikes a good balance between operational efficiency and efficacy stability[54,55].
In addition, multicenter data from real-world registry studies show that PFA has a clear advantage in terms of efficiency. Some reports indicate that, compared to traditional ablation techniques, PFA reduces the average procedural time by about 30%-50%, thus lowering risks related to radiation exposure, anesthesia time, and surgical trauma, while potentially reducing perioperative resource use and costs. This combination of high efficiency, high success rate, and good safety is a core advantage that is frequently cited in the clinical promotion of PFA[56].
Limitations of the evidence framework and future needs
Although the current evidence framework is relatively systematic, there are still limitations due to an imbalance in the clinical research landscape. The current significant evidence is primarily focused on mid- to short-term follow-up (typically around 12 months) and paroxysmal AF studies, with limited data on the long-term (3-5 years) maintenance of efficacy, atrial tissue electrical remodeling, and the need for re-ablation[57,58]. Furthermore, the number of high-quality RCTs is still limited. Except for a few studies like ADVENT and SPHERE PerAF, much of the data comes from registry cohorts or real-world evidence, which presents challenges in evaluating true comparative outcomes after eliminating bias through randomization[59,60].
Future clinical research should expand the scale and scope of RCTs, particularly focusing on different AF subtypes (e.g., long-term persistent AF, patients with high-risk heart failure), and should also track long-term follow-up results, quality of life, and broader cardiovascular events (such as stroke, heart failure exacerbation) that are meaningful for patient outcomes. Standardized ablation parameters, the impact of device iterations, and perioperative care strategies will also become important supports in advancing PFA’s integration into clinical practice[61,62].
Overall, clinical evidence for PFA in AF treatment is rapidly accumulating, showing that PFA has non-inferior or even superior trends in acute PVI success rates, one-year freedom from AF, safety, and procedural efficiency compared to traditional ablation techniques. These results come not only from single-center studies but also from multicenter real-world data, systematic reviews, and randomized trials, indicating that PFA is not just a technological innovation but also a treatment with strong clinical application potential[36]. However, to achieve broader evidence-based consensus and clinical guideline recommendations, further large-scale, long-term, high-quality RCTs are needed to strengthen the evidence base for this technology[63].
Optimization strategies for persistent AF
Unlike paroxysmal AF, persistent AF requires substrate modification beyond PVI. Recent 2025 data suggests that standard energy parameters may be insufficient for the thickened atrial myocardium found in the posterior wall or mitral isthmus[64]. Posterior wall isolation: The ADVANTAGE AF trial demonstrated that PFA can safely perform posterior wall isolation without the esophageal risks associated with thermal energy, achieving a 73.4% freedom from arrhythmia at 1 year. Optimization involves overlapping lesions by at least 30%-50% and utilizing “flower” configurations to ensure continuous transmurality[65,66]. Mitral isthmus and coronary spasm: Ablation of the mitral isthmus carries a unique risk of coronary spasm with PFA. Current protocols now mandate the prophylactic administration of nitroglycerin before applying energy to this region to prevent vasospasm[67,68]. Waveform evolution: The OMNY-IRE trial highlighted that optimizing waveforms (e.g., upgrading from “Pulse1” to “Pulse3”) significantly improved durable isolation rates from 51% to 97% upon remapping. This indicates that for persistent substrates, higher energy dosing or increased pulse train repetition is necessary to achieve IRE.
ADVANTAGES AND LIMITATIONS OF PFA COMPARED TO TRADITIONAL ABLATION
PFA not only differs from traditional thermal ablation methods (such as RFA and CBA) in its unique biophysical mechanism, but it has also demonstrated clinical outcomes in several studies that may surpass those of traditional methods. However, the true value of this technology requires a rational assessment through a precise comparison of its advantages and limitations[69].
Technical advantages: Safety and tissue selectivity
The core advantage of PFA lies in its non-thermal mechanism, which creates IRE in myocardial cell membranes through high-voltage, microsecond-duration electric fields, causing cell dysfunction without relying on heat or freezing to induce protein denaturation or cell death. This biophysical mechanism of selective damage mediated by the electric field provides significant protection to non-target tissues (such as the esophagus and nerve tissues)[70]. Traditional thermal methods, while creating lesions, risk non-selective damage to adjacent fragile structures, such as heat conduction to the esophageal wall or phrenic nerve, leading to complications like esophageal injury or phrenic nerve paralysis. In contrast, PFA significantly reduces these thermal injury events while ensuring PVI. Studies have shown that, in progressive evaluations, PFA’s tissue selectivity is superior to thermal ablation, laying the foundation for reducing the spectrum of complications[71,72].
Several comparative studies have shown that PFA significantly reduces total procedure time and left atrial dwell time when performing PVI compared to radiofrequency and CBA. Meta-analysis has indicated that PFA reduces the average procedure time by about 44 minutes and left atrial catheter dwell time by approximately 33 minutes compared to thermal methods. This efficiency improvement helps reduce intraoperative risks and may enhance patient tolerance[73].
In line with this, a large cohort study showed that, in persistent AF patients, PFA offered a significant advantage in shorter procedure times compared to traditional ablation methods. This is especially important in elderly patients or those with multiple comorbidities. While early comparative studies show that PFA’s freedom from AF recurrence at 12-month follow-up is not significantly different from thermal ablation techniques (non-inferior), there is a favorable trend in terms of complication rates[49]. For example, in some randomized controlled and real-world data, PFA shows a slightly lower or more mild adverse event rate while maintaining similar efficacy, providing initial evidence for PFA’s balance between effectiveness and safety[59,74]. Furthermore, direct comparison studies with CBA indicate that PFA has a lower risk of complications or fewer serious adverse events, supporting the view that PFA is more advantageous in terms of safety compared to thermal ablation[75,76].
Technical limitations and unresolved core issues
Despite the advantages outlined above providing theoretical support and initial evidence for the rapid clinical adoption of PFA, there remain important limitations or unresolved issues in several key areas[77]. Most of the available evidence on PFA is focused on short- or medium-term (typically within 12 months) recurrence rates and complication incidence. Data on long-term lesion durability, recurrence mechanisms, and electrical remodeling stability (over 3-5 years) are still relatively limited[78]. Although PFA shows comparable efficacy and a lower recurrence trend in the short term, further large-scale RCTs and long-term follow-up are needed to firmly establish its clinical advantage in long-term maintenance of sinus rhythm. Most of the current literature consists of mid- to short-term cohort studies or real-world evidence, lacking sufficient long-term pathological or re-ablation stage data[12,79].
This is particularly evident in the historical data of thermal ablation technologies. In contrast, traditional RFA and CBA have established clear long-term effect profiles through extensive long-term studies. Therefore, PFA needs to accumulate more long-term data to fill this crucial evidence gap[80,81].
While PFA demonstrates an advantage in total procedure time, several studies have pointed out that its fluoroscopy time is slightly longer than RFA. This may be related to the lack of real-time three-dimensional electroanatomical navigation integration and precise electric field targeting. Increased fluoroscopy time in certain patient groups may lead to additional radiation exposure, necessitating further optimization of navigation technology and electric field guidance strategies[82].
PFA technology is still rapidly developing, and there are currently various PFA device systems on the market, with differences in energy settings, electric field configurations, and ablation strategies. This presents challenges for cross-center comparisons, result standardization, and guideline development[83]. The lack of standardized parameters and established operating protocols can lead to heterogeneity in technical proficiency and treatment outcomes between different centers. Additionally, because PFA’s energy transfer mechanism differs fundamentally from traditional thermal ablation, operators need to adjust their ablation strategies, which introduces new learning curve challenges[84,85].
While the overall complication rate is low, some reports suggest that PFA may present complications distinct from those of thermal ablation, such as abnormal electric field reactions during the procedure or device-specific issues, which require further systematic evaluation. These risks are uncommon, but since PFA is still expanding across major centers, the true incidence and etiological mechanisms of such events need to be clarified through more rigorous long-term monitoring and safety studies[86].
Summary evaluation and clinical significance
Based on the current high-quality evidence, PFA demonstrates comparable efficacy to traditional thermal ablation techniques, with a potential advantage in surgical efficiency and tissue protection. PFA’s non-thermal mechanism fundamentally addresses the long-standing issue of thermal damage, significantly reducing the risk of adjacent tissue injury during the procedure, as validated by theoretical studies and multicenter real-world data[36].
However, current data is insufficient to prove that PFA is universally superior to traditional ablation techniques in all AF subtypes and long-term outcomes. Especially in patients with persistent AF and significant atrial structural remodeling, PFA’s lesion durability and long-term freedom from recurrence still require more large-scale RCTs for verification. Furthermore, varying operating standards across different device platforms and the lack of unified parameter guidelines present challenges for clinical adoption[12,87].
Therefore, the most valuable role for PFA may lie in a multimodal ablation strategy that combines personalized risk assessment with the strengths of traditional therapies: For patients at high risk of thermal injury, with fragile adjacent structures, or contraindications to traditional thermal ablation, PFA offers a safer alternative. For other complex pathologies or patients with high demands for long-term sinus rhythm maintenance, traditional techniques, combined with precise monitoring, still offer valuable guidance.
Technical considerations and lesion assessment
While thermal ablation relies on force-time integrals (ablation index), PFA lesion assessment is evolving towards electrogram-based markers. Unipolar signal modification: A landmark 2026 study identified that successful PFA lesions exhibit a specific “post-P-wave positive deflection” and the elimination of the S-wave in unipolar electrograms. A post-ablation unipolar voltage of < 0.4 mV has been validated as a robust predictor of durable scar formation[88].
Tissue proximity indication: Unlike thermal ablation where contact force is paramount, PFA requires “tissue proximity” to ensure adequate electric field coverage. New mapping systems now incorporate impedance-based tissue proximity indication algorithms to confirm electrode-tissue coupling before energy delivery[89]. Differentiation of stunning: To distinguish between “reversible” (stunning) and “irreversible” electroporation, a mandatory 20-minute waiting period followed by an adenosine challenge is recommended to detect early reconnection, a protocol now standard in trials like BEAT-PAROX-AF[90].
PERIOPERATIVE CARE STRATEGIES AND KEY POINTS
In AF catheter ablation (including PFA) treatment, perioperative care serves as a vital bridge between the implementation of the technique and the overall patient outcome. Nursing not only involves routine monitoring of vital signs and basic support but also plays a central role in interdisciplinary risk management, patient education, and rehabilitation interventions[41,91]. A review of perioperative management in AF catheter ablation emphasizes that, although specific practices may vary by center, perioperative management is critical to reducing complications and improving surgical success[92]. Nursing interventions span from preoperative, intraoperative to postoperative phases, focusing on risk assessment, complication prevention, patient education, and promoting adherence, all of which are closely linked to the final clinical outcomes[93].
Preoperative care: Risk assessment, education, and anticoagulation optimization
Preoperative care should include a thorough assessment system before patients decide to undergo PFA, encompassing a review of cardiac function (e.g., left ventricular ejection fraction, atrial size, heart failure severity), comorbidities (hypertension, diabetes, renal insufficiency), and medication history[94,95]. The assessment should also include a dual evaluation of thromboembolic and bleeding risks, using indicators such as CHA2DS2VASc and HAS-BLED scores, to guide anticoagulation strategy formulation. Current guidelines emphasize the priority of maintaining uninterrupted oral anticoagulation during the ablation perioperative period to reduce embolic risks[96,97].
Preoperative care should extend beyond biochemical indicators or physical signs to include an evaluation of the patient’s social support, cognitive ability, and potential psychological stress, as these factors are closely linked to the adequacy of preoperative preparation, postoperative adherence, and recovery[98,99]. Lack of comprehensive assessment in nursing may lead to increased intraoperative risks or delayed postoperative recovery, which has been consistently emphasized in multicenter practices[100,101].
Preoperative education is an evidence-based nursing intervention that helps patients understand the treatment goals, technical procedures, and potential risks through structured information delivery. Compared to traditional follow-up, education led by advanced practice nurses significantly enhances patients’ understanding of AF’s pathophysiology and the mechanisms of PFA, improves lifestyle changes (e.g., reducing alcohol intake, increasing physical activity), and significantly lowers AF recurrence rates within 6 months[102,103].
This phenomenon reflects the impact of psychological and behavioral pathways on physiological outcomes: Adequate preoperative education reduces patient anxiety, enhances self-management skills, and improves adherence to anticoagulation therapy and lifestyle modifications, key factors in improving perioperative safety and long-term prognosis[104,105].
Adjusting the anticoagulation regimen during the perioperative period is a core component of risk management. Current guidelines and practice consensus recommend uninterrupted oral anticoagulation before AF ablation, especially with direct oral anticoagulants, to minimize perioperative thromboembolic events[106]. Preoperative care should be based on individualized risk assessments, with the cardiovascular team jointly developing anticoagulation adjustment plans and clearly documenting medication cessation/continuation timelines, expected outcomes, and bleeding risks. Nurses should clearly explain the reasons for stopping anticoagulation medications and associated risks during preoperative visits to minimize patient misunderstandings and the risk of self-adjusting medications[106] (Figure 3).
Figure 3 The perioperative nursing strategies essential for optimizing patient outcomes in atrial fibrillation ablation procedures, including pulsed field ablation.
It covers preoperative risk assessment and education, intraoperative monitoring and complication prevention, and postoperative rehabilitation and health education. The figure emphasizes the importance of a comprehensive nursing approach to improving procedural success and long-term recovery. PFA: Pulsed field ablation; IRE: Irreversible electroporation.
Intraoperative care: Precision monitoring, dynamic coordination, and complication prevention
While PFA reduces the risk of thermal injury to adjacent tissues (e.g., esophagus, nerves) due to its non-thermal mechanism, there are still various potential complications during the perioperative period, including arrhythmias, bleeding at the puncture site, and vascular injury[107]. Intraoperative care is at the forefront of “risk identification and immediate intervention”. The core of intraoperative care lies in the highly sensitive monitoring of multiple physiological signals, including heart rate, blood pressure, pulse rate, oxygen saturation, and dynamic electrocardiogram changes, along with immediate analysis of potential arrhythmic changes[108]. Intraoperative nursing staff must be capable of identifying electrophysiological abnormalities, such as premature ventricular beats, bradycardia, and tachycardia, and must communicate and intervene with the interventional team and anesthesia team in the shortest time possible. Proper intraoperative monitoring can prevent and promptly respond to unexpected events during the procedure, thereby reducing complications[109,110].
The instantaneous electric field application during PFA catheter ablation can also lead to specific technical-related responses, such as transient AF induction or catheter instability, requiring close collaboration between the nursing and procedural teams to adjust catheter positioning, monitor electric field responses, and promptly assess the patient’s physiological status[111].
Ablation is an invasive procedure, so strict intraoperative sterile management and infection prevention are foundational to nursing care. Intraoperative care also requires coordination of dynamic adjustments to anticoagulation medications, such as joint decision-making with the interventional team based on real-time coagulation assessments (e.g., activated clotting time) regarding whether temporary adjustments to anticoagulation strategies are needed, which is crucial for preventing thromboembolic events[112].
Postoperative care: Monitoring, rehabilitation promotion, and continued health education
Postoperative care is an extension of intraoperative interventions and is a key phase in promoting long-term recovery and improving prognosis[100]. After PFA surgery, nursing staff must continuously monitor the heart rhythm, focusing on the restoration of sinus rhythm and monitoring for arrhythmias or paroxysmal ventricular events. Continuation of electrocardiographic monitoring can quickly identify postoperative AF recurrence, bradycardia/tachycardia, and collaborate with the medical team for timely treatment adjustments[113]. Early monitoring also includes assessing hemorrhagic complications (especially when anticoagulation strategies are not yet stable), puncture site bleeding, or hematoma formation. The perioperative care team should establish standardized postoperative observation protocols, including regular vital signs checks, puncture site evaluations, and monitoring of the neurological status[114,115].
Early postoperative rehabilitation (e.g., gradual rising, light activity) has been shown to positively enhance overall cardiopulmonary function, reduce hospital complications, and improve quality of life. Although evidence regarding early mobilization for AF catheter ablation patients is still accumulating, existing studies show that nurse-led early mobilization plans can be safely implemented, improving symptom rating scores and reducing unplanned follow-up visits[116].
Postoperative health education is critical for improving long-term outcomes. At this stage, nursing must emphasize the importance of anticoagulation/antithrombotic therapy, proper diet and posture control, lifestyle modifications (e.g., weight management, smoking cessation, alcohol reduction), and how to recognize early signs of recurrence or complications (e.g., chest pain, difficulty breathing, sudden palpitations)[117]. These educational topics must be combined with individualized risk factors, such as comprehensive management strategies related to AF, sleep apnea, obesity, etc., which are specifically outlined in the latest European Society of Cardiology guidelines for risk factor intervention[118].
High-quality evidence has shown that nurse-led postoperative interventions not only improve patients’ understanding of AF-related knowledge but also significantly reduce AF recurrence rates and poor lifestyle habits (such as excessive drinking), while increasing patient satisfaction and quality of life[119]. For example, integrating education and follow-up interventions led by advanced practice nurses into the perioperative care pathway can significantly reduce AF recurrence rates at 6 months and improve lifestyle indicators (such as alcohol intake and physical activity levels). This evidence-based result emphasizes that perioperative care is not just an observer during the procedure but plays a crucial role in promoting behavioral change and long-term disease management[120].
The value of nursing from risk management to long-term prognosis improvement
The role of perioperative care in the era of PFA has evolved from passive observation to active intervention, health promotion, and collaborative long-term management. Nursing interventions should include not only traditional monitoring of vital signs but also individualized risk assessments, patient education, anticoagulation optimization, early rehabilitation programs, and health behavior interventions[121,122]. Scientific nursing interventions can systematically reduce complications, enhance patient self-management, improve quality of life, and potentially reduce AF recurrence rates through behavioral change mechanisms. This comprehensive nursing pathway aligns closely with the latest integrated AF management strategies and is an indispensable component in establishing a high-quality AF treatment system[118,123].
THE IMPACT OF PERIOPERATIVE CARE ON PATIENT OUTCOMES
Perioperative nursing interventions are not only an auxiliary aspect of the technical process but also an essential component in ensuring patient safety, high-quality treatment, and long-term recovery. In the context of AF catheter ablation (including RFA and PFA), evidence-based nursing measures through multidimensional interventions have significantly improved key perioperative and postoperative outcomes, including reducing complication rates, shortening hospital stays, and enhancing patient satisfaction and quality of life[121]. This section will systematically summarize the effects of nursing interventions from the perspective of evidence-based research and explore their potential value in PFA treatment, supported by clinical data[124,125].
Nursing interventions significantly reduce perioperative complication rates
Although AF ablation surgery is a well-established technique, there are still various perioperative complication risks, such as bleeding, vascular injury, arrhythmias, postoperative confusion, and electrolyte disturbances. Traditional approaches to managing complications often rely on passive treatment, while proactive nursing interventions have been shown to significantly reduce complication rates[126,127].
A randomized controlled study comparing “high-quality nursing” with standard care in AF patients undergoing RFA showed that the experimental group had a significantly lower complication rate than the standard care group (P < 0.05) and also reported higher patient satisfaction[125]. The “high-quality nursing” in this study included enhanced preoperative risk assessments, continuous monitoring of vital signs, active intraoperative complication prevention, and close postoperative observation. These interventions demonstrated the central role of nursing in preventing complications. This mechanism of action can be understood from the following aspects: Preoperative risk screening and optimized care plans can identify high-risk factors (such as comorbid heart failure, increased thromboembolic risk), allowing for adjustments in anticoagulation, medication, and physiological state to reduce intraoperative and postoperative events[128]. High-precision monitoring and rapid response mechanisms allow nursing staff to detect arrhythmias, blood pressure fluctuations, or catheter-related responses early and intervene promptly. Standardized perioperative processes, such as anesthesia recovery, pain management, and vascular access safety assessments, guided by evidence-based nursing strategies, reduce common complication risks[129]. In summary, perioperative nursing interventions systematically reduce ablation-related complications, improving patient safety and eliminating clinical execution risks for the widespread adoption of PFA.
Nursing interventions shorten hospital stay and accelerate recovery
Shortening hospital stays is an important indicator of perioperative management quality, with significant medical and economic implications. Clinical observations show that implementing systematic nursing interventions (such as preoperative education, meticulous monitoring, and postoperative rehabilitation guidance) can promote early patient mobilization and accelerate physical recovery, resulting in significantly reduced postoperative hospital stays[130,131].
Early rehabilitation nursing research indicates that implementing nurse-driven early mobilization in AF patients post-RFA safely promotes postoperative recovery of activity, which is closely related to reduced venous thromboembolism risk, improved cardiopulmonary function, and better mental health[132]. Additionally, a randomized perioperative early rehabilitation nursing study showed that the early rehabilitation care group had shorter hospital stays and better outcomes in postoperative cardiac function markers (such as improved ejection fraction) and complication rates compared to the standard care group[133]. This suggests that comprehensive perioperative nursing interventions facilitate faster recovery and earlier discharge. These findings not only demonstrate the positive impact of nursing interventions on shortening hospital stays but also emphasize the indispensable role of postoperative rehabilitation plans in the overall treatment pathway[134].
Nursing interventions improve patient satisfaction and mental health
Another crucial dimension of perioperative nursing is improving patient experience and mental health. While ablation is minimally invasive, patients often experience anxiety, fear, and sleep disturbances, which can negatively affect heart rhythm stability and quality of life. Evidence-based nursing measures, including preoperative education, psychological support, and timely emotional interventions, help patients better understand the surgical process and enhance their self-management confidence[135]. For example, in the “high-quality care” group, patients’ overall satisfaction with nursing services was significantly higher than in the standard care group, indicating that nursing interventions not only support physiological recovery but also enhance patients’ trust and satisfaction with the treatment process and healthcare system, thus promoting active participation in postoperative rehabilitation[136].
Early rehabilitation nursing also contributes to improvements in psychological parameters, such as anxiety and depression, which are important for long-term quality of life. Studies have shown that structured psychological interventions and lifestyle adjustment plans can reduce postoperative anxiety and improve sleep quality, which have been included in the outcome assessments of high-quality nursing practices[133].
The role of nursing interventions in promoting long-term quality of life
While the direct goal of ablation surgery is to eliminate arrhythmias, improving long-term quality of life is also a core outcome of concern for patients. Evidence-based nursing strategies, including reinforcing postoperative health education, long-term follow-up, and risk behavior management (such as smoking cessation, weight control, and regular exercise), help patients establish healthy lifestyle habits, which have been shown to contribute to long-term rhythm stability and reduced AF burden[126].
Nurse-led lifestyle improvement interventions (including regular follow-ups, health counseling, and risk factor management) have been shown in multicenter real-world studies to sustainably improve patients’ cardiac health outcomes, further reducing symptom burden, readmission rates, and healthcare resource consumption[137,138]. In the context of PFA, this comprehensive perioperative nursing intervention framework becomes even more significant. Nursing support and guidance for long-term quality of life and behavioral changes serve as an important bridge to extending the benefits of ablation to improved quality of life[134].
Summary evaluation: Nursing as an amplifier of treatment outcomes
Overall, perioperative nursing interventions have a multifaceted and substantial positive impact on the outcomes of patients undergoing AF ablation: (1) Reduced complications: Risk assessment, meticulous monitoring, and standardized process management significantly reduce perioperative adverse events[121]; (2) Shortened hospital stay: Postoperative rehabilitation guidance and early mobilization accelerate physiological recovery; (3) Increased patient satisfaction: Education and psychological interventions improve treatment experience and adherence[139]; and (4) Improved quality of life: Long-term health behavior management helps continuously reduce AF burden. These outcomes are not only reflected in short-term postoperative metrics but also have a profound impact on long-term cardiovascular health and patient life. They provide typical evidence for viewing nursing as an amplifier of treatment outcomes rather than as an “auxiliary service”.
Future research and directions for nursing strategy enhancement
Although several studies have shown that perioperative nursing is beneficial for AF ablation outcomes, most existing research tends to be small-scale, single-center, or focused on traditional ablation techniques (e.g., radiofrequency). Specific nursing strategies for PFA (considering its unique electroporation mechanism, rapid energy application characteristics, and a different complication profile from thermal ablation) still lack systematic, high-quality RCTs[121].
Therefore, future studies should focus on multicenter, large-sample, long-term RCTs to clarify: The impact of different nursing intervention models on perioperative complications and postoperative rhythm stability outcomes in PFA patients; the contribution of nursing interventions to long-term quality of life, sustained health behavior changes, and health economics outcomes; research on personalized nursing pathways for high-risk populations (e.g., elderly patients, those with heart failure comorbidities)[140].
These evidence-based nursing studies will further enrich the PFA perioperative management system, providing stronger evidence for clinical guidelines and nursing standards. Current evidence clearly shows that perioperative nursing interventions, through multi-layered, comprehensive evidence-based approaches, effectively improve postoperative outcomes in AF ablation patients, making them an essential part of enhancing technical efficacy, reducing risks, and optimizing patient experience. As PFA technology evolves, nursing strategies must also evolve in tandem with its unique characteristics, developing evidence-based, refined perioperative nursing standards.
Future prospects and interdisciplinary collaboration
PFA, a revolutionary technology in the field of AF ablation, is in the critical stage of evolving from innovative clinical applications to standardized maturity. Numerous studies have demonstrated its safety and efficacy in the treatment of AF, offering directions for further optimization and providing a clear framework for future technological development, clinical integration, and perioperative care.
Future development directions of PFA technology
Although PFA has achieved PVI at multiple centers and has even been extended to persistent AF, its precision and lesion durability remain key areas of focus for future research. Current research indicates that PFA has an advantage in myocardial tissue selectivity; however, how to optimize different electric field parameters (e.g., voltage waveform, pulse length, frequency) and achieve consistent and reproducible lesion formation in complex left atrial anatomies still requires further investigation. Refined electric field models, three-dimensional electroanatomical navigation, and real-time imaging integration are expected to further enhance the precision and long-term stability of ablation.
Additionally, PFA near the coronary arteries may induce vasospasm, highlighting the need for the development of safer parameters and pre-treatment strategies (e.g., high-dose nitroglycerin pre-treatment) for different structures and physiological states to reduce specific risks. Several PFA systems are already approved for use, such as the FARAPULSE™ platform, which has expanded its indications to include persistent AF, marking a shift in clinical applications from paroxysmal AF to more complex pathologies. Future device development may focus on: Catheter designs with higher-density electric field control for more uniform and controllable lesion formation; integration of advanced imaging and electroanatomical mapping to enhance intraoperative localization and efficiency; specialized ablation modules for different AF subtypes to accelerate the widespread adoption of treatments. These technological innovations and device iterations will expand the use of PFA beyond initial ablation, potentially extending into complex lesions and re-ablation procedures.
Although short- and medium-term studies have shown promising safety and efficacy for PFA, long-term data remains insufficient. A major research task will be to evaluate PFA lesion durability, recurrence mechanisms, complication profiles, and re-ablation needs through standardized multicenter databases, real-world registries, and long-term follow-up studies. High-quality evidence-based data will not only support clinical guideline updates but also drive continuous technological improvements and expansion of clinical application boundaries.
The next phase of PFA research will be defined by large-scale RCTs addressing superiority and expanded indications: PRAISE (NCT06791629). This head-to-head RCT is specifically designed to compare PFA vs RFA in persistent AF, addressing the efficacy gap in complex substrate modification[141]. AVANT GUARD (NCT06096337): A pivotal study evaluating PFA as a first-line therapy for persistent AF compared to anti-arrhythmic drugs. If successful, this could fundamentally shift the treatment paradigm towards earlier intervention[11,142]. ReMATCH (NCT06735534): This trial investigates the safety and efficacy of PFA for redo procedures in patients who have failed prior ablation, leveraging PFA’s safety profile in scarred atria[143].
The potential value and development directions of perioperative nursing
As PFA moves from experimental to routine clinical use, perioperative nursing must evolve from traditional “monitoring and supportive tasks” to a more proactive, comprehensive management and long-term intervention approach. Perioperative nursing should not only perform standard monitoring tasks but also design customized care pathways based on specific patient risk profiles. For elderly patients or those with structural heart disease or multiple risk factors, the nursing team should collaborate with cardiology specialists to assess embolic risk, bleeding risk, and potential sensitivity to electric field reactions, forming a more precise individualized intervention plan. This stratified management approach will improve perioperative safety for PFA and reduce the incidence of adverse events.
This individualized nursing approach has been shown in other complex interventions to reduce postoperative complications, shorten recovery time, and enhance overall treatment outcomes. With the widespread adoption of telemedicine and wearable devices, perioperative nursing is no longer confined to the inpatient phase. Integrating remote monitoring systems into the nursing framework allows for dynamic postoperative heart rhythm monitoring, patient functional status assessment, and real-time symptom feedback, enabling early identification of AF recurrence, complications, or lifestyle behavior risks. This remote nursing model is expected to extend the window for nursing interventions, making perioperative care a truly dynamic and continuous health management model. For example, remote electrocardiogram monitoring of postoperative rhythm changes can provide early warning of AF recurrence, allowing time to adjust anticoagulation strategies or implement lifestyle interventions. For AF patients, the perioperative period is not only about management on the day of ablation but also marks the beginning of long-term cardiovascular health management.
Postoperative care should guide patients to actively engage in health behavior changes, such as weight control, blood pressure management, smoking cessation, limiting alcohol consumption, and regular exercise, all of which have been proven to significantly reduce the risk of AF recurrence. Therefore, perioperative nursing should extend into long-term postoperative interventions, collaborating with cardiology, rehabilitation medicine, and nutrition departments to create a multidisciplinary comprehensive management system.
The importance of multidisciplinary collaboration
The clinical value of PFA comes not only from the technology itself but also from the overall treatment effect achieved through a multidisciplinary collaborative framework. In electrophysiological procedures, nurses serve as the central link in the intraoperative and postoperative processes, requiring seamless collaboration with electrophysiologists, anesthesiologists, and rehabilitation specialists. For instance, when real-time monitoring detects abnormal electric fields affecting hemodynamics during the procedure, the nursing team’s quick response and effective communication are key to ensuring safety. Additionally, intraoperative emergency procedures, early identification and management of complications, and postoperative assessment and education all require close cooperation between nursing staff and clinical physicians.
Maximizing the clinical value of PFA requires the collaboration of multiple disciplines, including cardiology, anesthesiology, electrophysiology, nursing, rehabilitation medicine, and psychiatry. This collaborative model enables: Comprehensive risk assessment and development of personalized intervention plans; timely management of complex physiological responses during the procedure; ongoing health education and behavioral interventions postoperatively; reducing long-term recurrence and complication risks through cardiovascular rehabilitation and lifestyle management. This multidisciplinary collaboration not only enhances the outcomes of individual disciplines but also provides AF patients with continuous, closed-loop management from preoperative assessment to postoperative rehabilitation.
