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Patient and cardiologist discuss atrial fibrillation treatments, highlighting Boston Scientific PFA system.

ATRIAL FIBRILLATION

Staying ahead in AF treatment

Effective management of Atrial Fibrillation (AF) is multifaceted and challenging. It includes controlling symptoms, reducing stroke risk and addressing contributing lifestyle factors and comorbidities. Increasingly, it also involves proactively targeting the arrhythmia itself.1,2

Treatment options

Cardioversion

Defibrillator icon representing electrical cardioversion to restore sinus rhythm in patients with arrhythmias.

Electrical or pharmacological cardioversion may be used to restore sinus rhythm, particularly in patients with acute or worsening haemodynamic instability. Electrical cardioversion may also be used as diagnostic tool for patients with persistent AF to ascertain the value of sinus rhythm restoration on symptoms, or to assess improvement in left ventricular function.1,3

Drug therapies

Medicine bottle and pill icon symbolizing drug therapies for AF treatment with rate, rhythm control, and anticoagulants.

Where tolerated and not contraindicated, rate and rhythm control drugs are often the first approach for AF, typically combined with oral anticoagulants to mitigate the increased risk of stroke:

  • Rate-control therapies don’t impact the progression of AF or the frequency of episodes. NICE recommends the choice of drug be based on the patient’s symptoms, heart rate, comorbidities and preferences.3

  • Rhythm-control/antiarrhythmic drugs (AADs) aim to restore and maintain sinus rhythm and thus reduce the frequency or duration of AF episodes. NICE advises AADs should be considered in AF patients for whom a rate-control strategy has not been successful, potentially as a “pill-in-the-pocket” strategy.3 This guidance differs from European Society of Cardiology and US guidelines, which emphasise the importance of early rhythm control.1,4

  • Oral anticoagulation (OAC), prescribed to manage the 5-fold increased risk of stroke in AF patients,1 carries an increased bleeding risk that needs careful evaluation and management.³

Key facts

  • Paroxysmal AF that remains inadequately controlled with medication increases the risk of progression to persistent or permanent forms.5

  • NICE Guidelines on Diagnosis and Management of AF recommend:
    • Offering patients a personalised package of care3
    • Referring promptly at any stage in treatment if it fails to control the symptoms and more specialised management is needed (within 4 weeks of failed treatment or recurrence of AF after cardioversion)3

What are the alternatives to long-term medication?

Cardiac ablation

Pulmonary vein isolation (PVI) or left atrial ablation is a targeted, minimally invasive catheter ablation procedure that aims to ablate the electrical triggers of Atrial Fibrillation, rather than managing their consequences.

Meta-analyses of published studies show that, compared to drug therapy, catheter ablation is associated with benefits including reduced symptoms of AF, lower mortality rates, improved physical function and greater improvements in quality of life.5-13 Newly published research shows that the timing of catheter ablation can have an impact on the risk of arrhythmia recurrence.14

Catheter ablation is recommended by the European Society of Cardiology (ESC) as a first-line treatment strategy for paroxysmal AF; catheter ablation is also advised for certain other AF patients.1

FIRST-LINE RHYTHM CONTROL THERAPY

Classa

Levelb

Catheter ablation is recommended as a first-line option with a shared decision-making rhythm control strategy in patients with paroxysmal AF (Atrial Fibrillation), to reduce symtoms, recurrence, and progression of AF.

1

A

AF PATIENTS RESISTANT OR INTOLERANT TO ANTIARRHYTHMIC DRUG THERAPY

Classa

Levelb

Catheter ablation is recommended in patients with paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy to reduce symptoms, recurrence, and progression of AF.

1

A

PATIENTS WITH HEART FAILURE

Classa

Levelb

AF catheter ablation is recommended in patients with AF and HFrEF (Heart Failure with reduced Ejection Fraction) with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction.

1

B

Table adapted from Recommendation Table 18, 2024 ESC Guidelines for the Management of Atrial Fibrillation.1

a Class of recommendation
b Level of evidence


Ablation technology has evolved over the years to increase the precision and efficiency of the procedure and to minimise the risk of damage to healthy heart tissue or adjacent structures.

The evolution of catheter ablation technology: increasing precision, safety and effectiveness15-18

RADIOFREQUENCY ABLATION (RFA)

Radiofrequency ablation (RFA) with Boston Scientific's catheters.

First used for the treatment of AF in 1991, RFA uses highfrequency energy to create extreme heat to destroy target tissue19

CRYOBALLOON ABLATION

Cryoablation with Boston Scientific's catheters.

First used for the treatment of AF in 2005, cryoballoon ablation uses extreme cold to destroy target tissue20

PULSED FIELD ABLATION (PFA)

Pulsed field ablation (PFA) with Boston Scientific's catheters.

The FARAPULSETM PFA System was approved for use in Europe in 2021.21 PFA uses high amplitude pulsed electrical fields to destroy target tissue

The FARAPULSE Pulsed Field Ablation (PFA) System is a next-generation ablation technology, that generates high amplitude electric pulses to achieve PVI and has now been used to treat 500,000 patients worldwide.22 What sets FARAPULSE PFA apart from thermal ablation methods is a new level of tissue specificity that:

  • Minimises the risk of collateral damage to adjacent structures.15,16
  • Offers high freedom from arrhythmia recurrence and minimal arrhythmia burden post ablation.15,17,23
  • Improves the durability of pulmonary vein isolation.18

In addition, many patients experience minimal procedural pain and fast recovery times.24

The FARAPULSE PFA System features an innovative catheter design that takes a basket or flower-shape to adapt to the anatomy of the pulmonary veins to help ensure complete and effective ablation.
 

FARAPULSE™ PFA Catheter conforms to diverse pulmonary vein anatomies, ensuring efficient and reproducible results

FARAPULSE PFA is backed by over 10 years of research, including 55 clinical trials and more than 150 scientific publications to date.25 One pivotal randomised controlled trial, published in the New England Journal of Medicine, found that paroxysmal AF patients treated with FARAPULSE PFA showed a 73.3% treatment success rate at one year, with antiarrhythmic medication discontinued after the three-month blanking period.15 A more recently published study has shown comparable outcomes in persistent AF patients, with a primary effectiveness event-free rate at 12 months of 73.4% with FARAPULSE.23

Learn more about FARAPULSE PFA
Explore the evidence

Left atrial appendage (LAA) closure

LAA closure therapy, achieved with a minimally invasive catheter-based procedure using a device such as the WATCHMAN FLXTM implant, is an innovative one-time solution that offers an alternative to long-term anticoagulation therapy in patients with non-valvular AF and a high stroke risk, including those with a contraindication to OAC. It works by closing off the LAA with a permanent implant to prevent blood clots from escaping and causing stroke.

An RCT comparing WATCHMAN FLX to OAC (95% DOACs) after cardiac ablation has shown that the WATCHMAN FLX device was equally effective to OAC at 36 months, with a superior safety profile. The LAAC procedure can either be done in a concomitant procedure with catheter ablation or as a subsequential, separate procedure. There is ongoing research to establish the feasibility, safety and effectiveness of performing PVI with FARAPULSE PFA followed by LAA closure with WATCHMAN FLX in a combined procedure.26,27

REFERENCES:

1. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. doi:10.1093/eurheartj/ehae176.

2. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020;383(14):1305-1316. doi:10.1056/NEJMoa2019422.

3. NICE Guideline NG196. Atrial fibrillation: diagnosis and management. April 2021, updated June 2021 available at https://www.nice.org.uk/guidance/ng196/chapter/Recommendations (last accessed May 2025)

4. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149:e1–e156. doi: 10.1161/CIR.0000000000001193

5. Poole JE, Bahnson TD, Monahan KH, et al. CABANA Investigators and ECG Rhythm Core Lab. Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial. J Am Coll Cardiol. 2020;75(25):3105–3118. doi: 0.1016/j.jacc.2020.04.065.

6. AlTurki A, Proietti R, Dawas A, et al. Catheter ablation for atrial fibrillation in heart failure with reduce ejection fraction: a symptomatic review and meta-analysis of randomized controlled trials. BMC Cardiovasc Disord. 2019;19(1):18. doi: 10.1186/s12872-019-0998-2.

7. Asad ZUA, Yousif Ali, Khan MS, et al. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circ Arrhythm Electrophysiol. 2019;12(9):e007414. doi: 10.1161/CIRCEP.119.007414.

8. Khan SU, Rahman H, Talluri S et al. The Clinical Benefits and Mortality Reduction Associated With Catheter Ablation in Subjects With Atrial Fibrillation: A Systematic Review and Meta-Analysis JACC Clin Electrophysiol. 2018;4(5):626-635. doi: 10.1016/j.jacep.2018.03.003

9. Ruzieh M, Foy AJ, Aboujamous NM, et al. Meta-Analysis of Atrial Fibrillation Ablation in Patients with Systolic Heart Failure. Cardiovasc Ther. 2019:8181657. doi: 10.1155/2019/8181657.

10. Turagam MK, Garg J, Whang W, et al. Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials. Ann Intern Med. 2019;170(1):41-50. doi: 10.7326/M18-0992

11. Chen C, Zhou X, Zhu M, et al. Catheter ablation versus medical therapy for patients with persistent atrial fibrillation: a systematic review and meta-analysis of evidence from randomized controlled trials. J Interv Cardiovasc Electrophysiol. 2018;52(1):9-18. doi: 10.1007/s10840-018-0349-8

12. Calkins H, Hindricks G, Cappato R, et al. Heart Rhythm. HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-e444. doi: 10.1016/j.hrthm.2017.05.012.

13. Allan KS, Aves T, Hentry S, et al. Health-Related Quality of Life in Patients with Atrial Fibrillation Treated With Catheter Ablation or Antiarrhythmic Drug Therapy: A Systematic Review and Meta-analysis. CJC Open. 2020;2(4):286-295. doi: 10.1016/j.cjco.2020.03.013.

14. Karakasis P, Tzeis S, Pamporis K, et al. Impact of catheter ablation timing according to duration of atrial fibrillation history on arrhythmia recurrences and clinical outcomes: A meta-analysis. Europace. 2025 May 28:euaf110. doi: 10.1093/europace/euaf110. Epub ahead of print.

15. Reddy VY, Gerstenfeld EP, et al; ADVENT Investigators. Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2023;389(18):1660-1671. doi: 10.1056/NEJMoa2307291.

16. Ekanem, E, Neuzil, P, Reichlin, T et al. Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17K study. Nat Med. 2024;30(7):2020-2029 doi.org/10.1038/s41591-024-03114-3

17. Reddy VY, Mansour M, Calkins H. Pulsed Field vs Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation: Recurrent Atrial Arrhythmia Burden. J Am Coll Cardiol. 2024 Jul 2;84(1):61-74. doi: 10.1016/j.jacc.2024.05.001.

18. Della Rocca DG, Marcon L, Magnocavallo M, et al. Pulsed electric field, cryoballoon, and radiofrequency for paroxysmal atrial fibrillation ablation: A propensity score matched comparison. Europace. 2023;26(1):euae016.

19. Ghzally Y, Ahmed I, Gerasimon G. Catheter Ablation. [Updated 2023 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470203/. Last accessed May 2025.

20. Yang H, Xiang J, Shen J, et al. Global Research Trends of Cryoablation for Atrial Fibrillation from 2002 to 2022: A Bibliometric Analysis. Anatol J Cardiol. 2023;27(12):688-696. doi: 10.14744/AnatolJCardiol.2023.

21. Cardiac Rhythm News. 29 January 2021. Available at: https://cardiacrhythmnews.com/farapulse-gains-ce-mark-for-its-pulsed-field-ablation-system/. Last accessed May 2025.

22. BSC data on file. 2025

23. Reddy VY, Gerstenfield EP, Schmidt B, et al. Pulsed Field Ablation of Persistent Atrial Fibrillation With Continuous ECG Monitoring Follow-Up: ADVANTAGE AF-Phase 2. Circulation. Published online April 2025. doi:10.1161/CIRCULATIONAHA.125.074485

24. Füting A, Neven K, Howel D et al. Patient discomfort following pulsed field ablation for paroxysmal atrial fibrillation – an assessment of chest and groin pain using the Numeric Rating Scale. Clin Res Cardiol (2021). 10.1007/s00392-021-01933-9

25. FARAPULSE Clinical Compendium.

26. ClinicalTrials.gov ID NCT06861673. COnCOmitaNt Pulse Field Ablation Based pUlmonary Vein Isolation and lefT Atrial Appendage Closure - The COCONUT Study.

27. ClinicalTrials.gov ID NCT06686485. cOncomitant Left Atrial aPpendage Closure and Pulsed Field ablaTION-Asia - OPTION-A

CAUTION:

The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings, and instructions for use can be found in the product labelling supplied with each device or at www.IFU-BSCI.com. Products shown for INFORMATION purposes only and may not be approved or for sale in certain countries. This material not intended for use in France.