Epicardial lead dysfunction after pulsed field ablation: early clinical experience from a case series
V Pasara, G Vetta, A Sorgente, A Del Monte, J A Sieira Rodriguez-Moret, L Pannone, V Velagic, G Bala, E Stroker, A Almorad, P A Calburean, A Sarkozy, C De Asmundis, G B Chierchia, D G Della RoccaAbstract
Background
Pulsed field ablation (PFA) is a non-thermal ablation modality with a favorable safety profile, but data on its use in patients with cardiac implantable electronic devices (CIEDs), particularly those with epicardial leads, are limited.
Purpose
To describe the incidence, characteristics, and clinical implications of epicardial lead dysfunction following PFA.
Methods
Between November 2022 and December 2024, seven patients (85% male, mean age 54.7 years) with CIEDs and 12 epicardial plus 4 transvenous leads underwent PFA for atrial arrhythmias. PFA was performed with the Farapulse system (n=4) or Affera system (n=3). Device interrogation was performed pre- and post-procedure. Changes in sensing, pacing thresholds, and impedance were evaluated peri-procedurally and at follow-up.
Results
Epicardial lead dysfunction occurred in 5 of 7 patients (71.4%), affecting 7 of 12 epicardial leads (58.3%). Atrial lead dysfunction (n=5) included sensing deterioration in three cases, one of which showed complete loss of atrial signals. One patient experienced transient loss of atrial capture and undersensing during left superior pulmonary vein isolation, with partial recovery within 24 hours. Pacing thresholds increased in five cases, and one lead demonstrated a persistent impedance rise. Ventricular lead dysfunction (n=2) manifested as increased pacing thresholds in both cases. At follow-up, dysfunction persisted in four cases, while one recovered fully. Two patients exhibited no relevant changes in epicardial lead parameters.
Conclusion
In our early clinical experience, epicardial lead dysfunction was frequently observed after PFA, affecting both atrial and ventricular leads. Manifestations included sensing impairment, increased pacing thresholds, and impedance fluctuations, with variable recovery. These findings suggest potential electroporation-related effects at the lead–tissue interface and underline the need for careful peri-procedural monitoring. Particular caution is warranted when considering PFA for patients with epicardial leads, especially those who are pacemaker-dependent or reliant on stable cardiac resynchronization therapy.Lead parameter trends over time