The energy war ended fast. Pulsed field ablation (PFA) went from roughly 35% of AFib ablation catheter spend in 2024 to roughly 78% by early 2026. Today there are six FDA-approved PFA-capable platforms across five manufacturers competing for the same hospital EP labs: Farapulse (Boston Scientific), PulseSelect and Affera/Sphere-9 (Medtronic), Varipulse (Johnson & Johnson MedTech), Volt (Abbott), and Globe (Kardium).
How brutal is that fight? Boston Scientific built the commercial PFA category. Farapulse was first commercialized in Europe in 2021, before Boston Scientific even acquired the company. Last week they told investors EP sales fell 5% and that they expect continued share loss through 2027, which they're calling the "trough" year. Meanwhile Medtronic's ablation business grew 88% last quarter (139% in the US).
There's a lesson buried in that reversal. Medtronic's PulseSelect was actually the first PFA system through the FDA, in December 2023, and that head start protected nothing either. Being first in Europe and first through the FDA protected no one in the energy war. I wouldn't bet on incumbency holding in the next war either.
Ten months ago, CMS added AFib ablation to the ASC covered procedures list, with commercial payers and Medicare Advantage plans following Medicare's lead. Watch the field behavior since:
Device makers see the ambulatory channel as contestable ground and are targeting gains outside the hospital.
And keep an eye on the wildcard: Kardium. A single catheter that maps and ablates with no separate mapping system is, on paper, the lightest capital footprint in the field, with no hospital installed base to protect. Nobody has declared an ASC strategy yet. Watch where the next wave of first cases shows up.
Electrophysiologists and hospital cardiovascular leaders push back, each fair, but not one is a true clinical barrier. They're alignment barriers, and alignment barriers are solvable.
True today. Hospitals offer salaries private practice has struggled to match, and once employed, there is no reason to leave a fully equipped hospital EP lab. But incentive structures are not fixed. New partnership models are emerging that align EP physicians with ownership, sustainability, and outcomes in ways W-2 employment never will.
Complex and multiple arrhythmias, anesthesia risk, and high-deductible patients that slim ASC margins can't absorb will keep a meaningful share of cases hospital-based, where they belong. Patient selection matters, but patient demand and the market is growing. Aging populations and underserved demand guarantee both settings will be busy for decades.
Exactly. That's the point. Ownership is the alignment mechanism. Physicians who did their first ASC ablation cases are reporting the same thing: patients love the experience, costs are lower, and the procedures are safe in the right patient. The operators making the move are the ones with skin in the game.
The most common prediction I hear is that ASCs and hospitals will cohabitate, with hospitals keeping the complex cases. Agreed. But cohabitation framing misses the bigger story.
Here's what Atria Health is seeing in communities across the country: demand was never fully captured by the hospital setting in the first place. There is a large population of patients, especially in rural markets, who have been parked on antiarrhythmic drugs for years. Those drugs are not benign. When ablation shows up in their community at an accessible price point, that's not volume shifting from the hospital. That's untapped demand finally being served.
Everybody wins when supply and setting match community demand. Especially the patient.
The shift to ASCs changes more than where procedures happen. Some argue it changes who makes purchasing decisions. I'd put it differently: not "who," but "how." Physicians should always lead purchasing decisions. What changes is that physicians in ownership positions are now aligned to sustainability and value-based medicine when they make them.
