By Lars Thording

Pulsed field ablation (PFA) is rapidly changing how we treat atrial fibrillation (AFib). AFib ablation is moving out of the hospital (at least some of it). And Boston Scientific is upsetting the competitive map of electrophysiology.

I have always said that change never happens as fast as we think in electrophysiology, but the past years have proven me wrong. Things are changing in a big way — fast. These changes were on display at this year’s Heart Rhythm Society (HRS) conference, the annual conference for physicians, scientists, technologists, and suppliers in the field of electrophysiology.
The rise of PFA
Electrophysiology has long been an area of special interest in cardiology and in healthcare in general. This is because AFib diagnoses are seeing double-digit growth every year, which drives heavy investments in AFib technology and creates artificially short product life cycles.

However, for the past decades, these technology changes have been incremental (some might say more formal than substantial), and the industry has seemed frozen in terms of competitive powers and dynamics: Biosense Webster (now J&J Medtech) and Abbott have been the volume leaders in radiofrequency (RF) ablation. Medtronic has come in third with its cryo-ablation, and Boston Scientific has been a distant fourth in market share, although some technologists and physicians would argue that its mapping system was the most advanced.

Enter PFA. Medtronic’s PulseSelect system was cleared in December 2023. But it was Boston Scientific’s FARAPULSE system (launched fall of 2024) that really broke open the PFA market. Boston Scientific became the market leader in PFA ablation, even after VARIPULSE (J&J Medtech) and Affera (Sphere-9) from Medtronic were launched. Today, FARAPULSE has lost some share to the other PFA systems, but it remains the market leader (for now).

At HRS, all of these systems were at display, and it is clear that the transition from RF to PFA is happening very fast — much faster than typical technology changes in electrophysiology. What’s driving this development is the promise of much faster procedures, better safety, and, possibly, better outcomes. RF is not going away (PFA is not the ideal approach in all cases), but PFA is quickly becoming the dominant approach to AFib treatment.

The faster procedure is important for a couple of reasons:

First, it will allow healthcare facilities to conduct more procedures on more patients, which is very appealing from a population health perspective, given that only a fraction of the patients that could benefit from AFib ablation actually get AFib ablation procedures today. PFA ablation catheters are priced much higher than RF catheters. Given that medical device costs in a PFA procedure are at least 25% higher than in an RF procedure, healthcare facilities actually have to do more procedures to pay for the technology.

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