INTRODUCTION: Pulsed electric field (PEF) has emerged as a promising energy source for catheter ablation of atrial fibrillation (AF). However, data regarding the in-vivo effect of PEF energy on erythrocytes during AF ablation procedures are scarce. This study aimed to quantify the impact of PEF energy on erythrocyte damage during AF ablation by assessing specific hemolytic biomarkers. METHODS: A total of 60 patients (age: 68 years, males: 72%, serum creatinine: 91 µmol/L) with AF underwent catheter ablation of AF using PEF energy delivered by a multipolar pentaspline Farawave catheter (Farapulse, Boston Scientific, Inc.). Ablation beyond pulmonary vein isolation was performed at the operator's discretion. Peripheral venous blood was sampled for assessing the plasma levels of free hemoglobin (fHb), direct (conjugated) bilirubin, lactate dehydrogenase (LDH), and creatinine before, immediately after the ablation, and on the next day. RESULTS: Following the PEF ablation with duration of [median (interquartile range)] 75 (58, 95) min, with 74 (52, 92) applications and PVI only in 27% of patients, fHb, LDH, and direct bilirubin significantly increased, from 40 (18, 65) to 493 (327, 848) mg/L, from 3.1 (2.6, 3.6) to 6.8 (5.0, 7.9) µkat/L, and from 12 (9, 17) to 28 (16, 44) µmol/L, respectively (all p < .0001). A strong linear correlation was found between the peak fHb and the number of PEF applications (R = 0.81, p < .001). The major hemolysis (defined as fHb >500 mg/L) was predicted by the number of PEF applications with the corresponding area under the receiver operating characteristic curve of 0.934. The optimum cut-off value of >74 PEF applications predicted the major hemolysis with 89% sensitivity and 87% specificity. CONCLUSION: Catheter ablation of AF using PEF energy delivered from a pentaspline catheter is associated with significant intravascular hemolysis. More than 74 PEF applications frequently resulted in major hemolysis. However, the critical amount of PEF energy that may cause kidney injury in susceptible patients remains to be investigated.

Department of Biochemistry Institute for Clinical and Experimental Medicine Prague Czechia

Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czechia

Department of Clinical Sciences and Community Health Cardiovascular Section University of Milan Milan Italy

Institute of Physiology Charles University Medical School 1 Prague Czechia

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Reddy VY, Gerstenfeld EP, Natale A, et al. Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med. 2023;389:1660‐1671. PubMed

Cochet H, Nakatani Y, Sridi‐Cheniti S, et al. Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation. EP Europace. 2021;23:1391‐1399. PubMed PMC

Kinosita K, Tsong TT. Hemolysis of human erythrocytes by transient electric field. Proc Natl Acad Sci. 1977;74:1923‐1927. PubMed PMC

Vallelian F, Buehler PW, Schaer DJ. Hemolysis, free hemoglobin toxicity, and scavenger protein therapeutics. Blood. 2022;140:1837‐1844. PubMed PMC

Venier S, Vaxelaire N, Jacon P, et al. Severe acute kidney injury related to haemolysis after pulsed field ablation for atrial fibrillation. Europace. 2023;26:euad371. PubMed PMC

Mohanty S, Casella M, Compagnucci P, et al. Acute kidney injury resulting from hemoglobinuria after pulsed‐field ablation in atrial fibrillation. JACC Clin Electrophysiol. 2024;10(4):709‐715. PubMed

Extracorporeal Life Support Organization . ELSO Guidelines for Cardiopulmonary Extracor‐poreal Life Support. Version 1.3, November 2013. Accessed January 24, 2023. http://www.elso.org/portals/0/igd/archive/filemanager/929122ae88cusersshyerdocumentselsoguidelinesgeneralalleclsversion1.3.pdf

Van Edom CJ, Gramegna M, Baldetti L, et al. Management of bleeding and hemolysis during percutaneous microaxial flow pump support. JACC Cardiovasc Interven. 2023;16:1707‐1720. PubMed

Bao N, Le TT, Cheng J‐X, Lu C. Microfluidic electroporation of tumor and blood cells: observation of nucleus expansion and implications on selective analysis and purging of circulating tumor cells. Integr Biol. 2010;2:113. PubMed PMC

Kaminska I, Kotulska M, Stecka A, et al. Electroporation‐induced changes in normal immature rat myoblasts (H9C2). Gen Physiol Biophys. 2012;31:19‐25. PubMed

Reddy VY, Koruth J, Jais P, et al. Ablation of atrial fibrillation with pulsed electric fields. JACC Clin Electrophysiol. 2018;4:987‐995. PubMed

Ekanem E, Reddy VY, Schmidt B, et al. Multi‐national survey on the methods, efficacy, and safety on the post‐approval clinical use of pulsed field ablation (MANIFEST‐PF). EP Europace. 2022;24:1256‐1266. PubMed PMC

Schmidt B, Bordignon S, Neven K, et al. EUropean real‐world outcomes with pulsed field ablation in patients with symptomatic atRIAl fibrillation: lessons from the multi‐centre EU‐PORIA registry. Europace. 2023;25:euad185. PubMed PMC

Reddy VY, Ekanem E Multi‐national survey on the safety of the post‐approval use of pulsed field ablation in 17000+ patients (MANIFEST‐17K). Presented this at the AHA Late Breaking & Featured Science—Scientific Sessions November 11, 2023. Philadelphia, PA AHA. 2023.

Nies M, Koruth JS, Mlček M, et al. Hemolysis after pulsed field ablation: impact of lesion number and catheter‐tissue contact. Circ Arrhythm Electrophysiol. 2024;17(6):e012765. PubMed

Jordan F, Knecht S, Isenegger C, et al. Acute kidney injury after catheter ablation of atrial fibrillation: comparison between different energy sources. Heart Rhythm. 2024;21:1248‐1249. PubMed

Meegan JE, Bastarache JA, Ware LB. Toxic effects of cell‐free hemoglobin on the microvascular endothelium: implications for pulmonary and nonpulmonary organ dysfunction. Amer J Physiol Lung Cell Molec Physiol. 2021;321:L429. PubMed PMC