Analysis · Cardiac Ablation · Medtech Trends
Dual-energy ablation: the second wave of PFA adoption
Cardiac ablation switched from thermal to pulsed field in under two years. Dual-energy RF+PFA catheters are the second wave. Here's the adoption data and the forecast.
The story everyone tells about cardiac ablation is pulsed field versus thermal. The more important story is the one starting right now: catheters that do both.
On July 9, 2026, J&J won FDA approval for its Dual Energy Thermocool SmartTouch SF platform, a single catheter that toggles between radiofrequency and pulsed field ablation mid-procedure. It follows Boston Scientific's Farapulse, Medtronic's PulseSelect and Sphere-9, and J&J's own Varipulse. But the "dual energy" part is the signal worth reading. The first wave of PFA was one energy replacing another. The second wave is one catheter carrying both.
There are actually two different trends here, and conflating them is the most common mistake I see.
Two trends, not one
PFA adoption is not the same as dual-energy adoption
The first trend is overall adoption of PFA versus RF and cryo. That curve is steep and well documented. The second is adoption of dual-energy RF+PFA catheters, the newer point-by-point systems like Sphere-9. That trend is much younger and has far less historical data.
The 20–30% figure RBC quotes is not 20–30% of all AF ablations. It comes from physician channel checks, and it refers to 20–30% of procedures using dual-energy catheters in the segments where they are available, particularly more complex cases. Read carelessly, it makes dual-energy look twice as penetrated as it is.
The first wave of PFA was a material swap. Dual-energy is a workflow change, and workflow changes compound.
The best trend line we can build today
The public data comes from commercial availability, IDE studies, the European surveys, and the U.S. registries. Put together, the two curves look like this.
| Year | PFA adoption | Dual-energy RF+PFA | Evidence |
|---|---|---|---|
| 2020 | 0% | 0% | PFA not commercially available |
| 2023 | <1% | 0% | Early IDE studies only |
| Early 2024 | ~5–10% US | ~0% | First commercial PFA rollout |
| Late 2024 | ~20–30% | <5% | Rapid Farapulse adoption |
| Mid-2025 | ~49% of first AF ablations (EU) | ~5–10% | EHRA survey |
| Mid-2026 | ~60% PFA-only + ~15% PFA+RF (US) | ~15–30% | US registry + RBC channel checks |
Chart values are midpoints of the reported ranges. Switch to Data for the exact figures and the evidence behind each point.
The strongest dataset published to date
The most useful number set comes from a registry of 158 U.S. electrophysiology centers, tracking energy-source adoption across the first 15 months after U.S. commercialization of PFA. The transition is one of the fastest technology switches cardiology has seen.
| Energy source | Commercial launch | ~15 months later |
|---|---|---|
| RF | 72% | 22% |
| Cryoballoon | 16% | 2% |
| RF + Cryo | 12% | 1% |
| PFA | 0% | 60% |
| PFA + RF | 0% | 15% |
Two things jump out. PFA went from zero to a clear majority. And the dual-energy line, PFA+RF, went from zero to 15% in the same window, before most dual-energy catheters were even available.
Europe is moving the same direction
The EHRA survey comparing practice in 2020 versus 2025 tells a parallel story: RF dropped sharply, cryo dropped sharply, and nearly half of first AF ablations are now PFA.
For repeat procedures, dual-energy point-by-point catheters account for nearly 40% of PFA catheter choices. In difficult anatomy, physicians want to switch between RF and PFA within the same case, and that is the whole reason dual-energy exists.
Why physicians want both energies
Neither energy wins everywhere. Physicians reach for each in different anatomy, and the value of dual-energy is not having to choose at the start of the case.
| Scenario | Preferred energy | Why |
|---|---|---|
| Posterior wall, near the esophagus | PFA | Tissue-selective; spares the esophagus |
| Fast pulmonary vein isolation | PFA | Speed on the standard lesion set |
| Thick myocardium, carina, the ridge | RF | Durable focal lesions where PFA can be shallow |
| Near coronary arteries | RF | Predictable, controllable depth |
| Touch-up lesions | RF | Durability on the gaps that cause redos |
The ability to toggle between RF and PFA without exchanging catheters is the primary value proposition. As J&J's electrophysiology chair Michael Bodner put it, the toggle gives physicians "a lot of versatility, depending on the complexity of the patient."
The leading indicator to watch
Physicians are already using both energies in the same case, which is the clearest sign this is a real workflow and not a trial. A 2026 series using a dual-energy lattice-tip catheter reported the mix directly.
Nearly nine in ten cases used both energies, and the per-case counts show it was not a token application. Physicians were building lesion sets out of both modalities, choosing energy by anatomy. That is what durable adoption looks like, not a pilot.
The forecast
If adoption continues along the observed PFA curve, the U.S. registry, and the channel checks, dual-energy share tracks roughly like this. This is an extrapolation, not published market data. Read it as a forecast, not history.
| Year | Estimated dual-energy share |
|---|---|
| 2024 | <5% |
| 2025 | 5–10% |
| 2026 | 20–30% |
| 2027 | 35–45% |
| 2028 | 45–60% |
Forecast only. Chart values are midpoints; switch to Data for the reported ranges.
Forecast only. Extrapolated from the observed PFA adoption curve, the 158-center U.S. registry, and RBC physician channel checks. Not published market data; actual share will move with reimbursement, catheter availability, and clinical-outcome readouts.
Follow the money
The adoption curve is not running on enthusiasm. It is running on capital, and the size of the checks says the incumbents and their backers believe the switch is permanent.
The strategic bets came first. Boston Scientific paid $295 million in 2021 for the 73% of Farapulse it did not already own, plus up to $92 million in milestones. Medtronic followed with a $925 million acquisition of Affera in 2022, and that deal is where the Sphere-9 dual-energy lattice-tip catheter came from. The second wave was bought before it shipped.
The independents are still raising, and not in small amounts. Kardium pulled in $104 million in 2024 and another $250 million in 2025 to launch its PFA system. Field Medical closed a $35 million Series B in 2025 to push pulsed field into ventricular tachycardia, bringing it to roughly $75 million raised.
Hospitals spent an estimated $1.1 billion on capital equipment across 2024 and 2025 swapping aging RF generators for pulsed-field consoles. Once that install base is in place, it pulls catheter demand behind it for a decade.
| Deal | Type | Amount | Year | Note |
|---|---|---|---|---|
| Boston ScientificFarapulse | Acquisition | $295M + up to $92M milestones | 2021 | Bought the 73% stake it did not already own |
| MedtronicAffera | Acquisition | $925M | 2022 | Source of the Sphere-9 dual-energy catheter |
| Kardium | Venture | $104M then $250M | 2024–2025 | Scaling to launch its PFA system |
| Field Medical | Venture (Series B) | $35M | 2025 | Pushing PFA into ventricular tachycardia |
The XO take
From a sourcing desk, the interesting part is not the clinical story. It is what dual-energy does to the bill of materials.
A thermal-only catheter is a mature build. A dual-energy catheter is not. It has to carry an electrode architecture that survives both RF heating and high-voltage PFA pulses, pair to a generator that delivers two fundamentally different energy profiles, and hold tolerances tight enough that the toggle is seamless in the cath lab. That is a harder manufacturing problem than either energy alone, and it lands right as OEMs are racing to field second-generation systems against Farapulse's head start.
That gap is the opportunity. The device teams moving now need contract partners who already understand high-voltage pulse delivery, fine-wire and lattice-tip electrode construction, and the biocompatibility and verification burden that comes with a new energy modality, not partners who will learn it on the program. The first wave of PFA rewarded whoever shipped a working catheter first. The second wave will reward whoever can build a catheter that does two things at once, at volume, with a regulatory package that de-risks it for the OEM.
The thermal-to-PFA switch is nearly done. The single-to-dual-energy switch is just starting. The window is open.