REPRESENT-PF: Advancing Equitable Atrial Fibrillation Care Through Real-World Evidence

Interview With Emmanuel Ekanem, MD

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EP LAB DIGEST. 2026;26(10).

Interview by Isabel Vega 

In this interview, Emmanuel Ekanem, MD, of Valley Health Winchester Medical Center discusses the REPRESENT-PF Registry, the importance of improving representation in atrial fibrillation (AF) research, and how real-world data from the FARAPULSE™ PFA platform (Boston Scientific) could help advance more equitable patient care.

Winchester Medical Center was the first site in the nation to enroll and treat patients in the REPRESENT-PF Registry. What does that achievement mean for your team?
It's a significant point of pride for our team at Valley Health Winchester Medical Center. As the registry's national principal investigator, and with Winchester Medical Center serving as the first enrolling site, this milestone is meaningful both personally and institutionally. Being the first to enroll reflects not only our readiness, but also our commitment to addressing an important gap in AF research. I'm especially grateful to Dr Vivek Reddy of Mount Sinai, the registry's sponsor-investigator, whose leadership has been instrumental in launching this effort.

Leading the REPRESENT-PF Registry allows us to help build the evidence base that has been missing and positions our program at the forefront of a national effort to generate more representative data for pulsed field ablation (PFA). This milestone reflects our commitment to delivering advanced, equitable cardiovascular care to every patient we serve.

Can you tell us about the REPRESENT-PF Registry, what prompted its development, what its primary goals are, and what researchers hope to better understand about the safety and effectiveness PFA in historically underrepresented populations?
REPRESENT-PF is a pragmatic, prospective, multicenter observational registry designed to evaluate the real-world safety and effectiveness of the FARAPULSE PFA Platform in underrepresented racial and ethnic minority patients with AF. Unlike a clinical trial, participants receive commercially available, FDA-cleared technology as part of routine clinical care. The registry will enroll up to 275 patients across as many as 25 sites, with follow-up before ablation, at the time of the procedure, and at 3, 6, and 12 months post-ablation.

The registry was developed to address a critical evidence gap. Although catheter ablation is increasingly used as first-line therapy for symptomatic AF and PFA has demonstrated an excellent safety profile with efficacy comparable to conventional thermal ablation, racial and ethnic minority populations have been underrepresented in the studies establishing that evidence. For example, the pivotal Pentaspline PFA trial enrolled only 2.9% minority patients—too few to draw meaningful conclusions about safety and effectiveness in these populations.

That gap is particularly important because existing data suggests outcomes may differ. A subgroup analysis of the CABANA trial found a 68% relative reduction in the composite primary endpoint and a 72% relative reduction in all-cause mortality among minority patients randomized to ablation versus drug therapy. However, those findings were based on a relatively small subgroup and were not the primary focus of the study.

By prospectively enrolling underrepresented minority patients, REPRESENT-PF aims to generate the largest prospective dataset of its kind and determine whether the safety and effectiveness of PFA seen in previous studies extend to the diverse patient populations treated in everyday practice.

Why is it important that these patients are represented in clinical research, and how could the findings influence future standards of care?
Representation in clinical research is essential because it ensures that clinical guidelines reflect the full spectrum of patients we treat rather than a limited subset. When these patients are underrepresented in studies evaluating safety and efficacy, the resulting uncertainty can become another barrier to referral and treatment.

If REPRESENT-PF confirms that PFA is as safe and effective in underrepresented minority populations as it has been shown to be in broader clinical trials, clinicians will have population-specific evidence to support earlier referral for ablation rather than relying primarily on drug therapy. Just as importantly, the registry may help address apprehension among patients by providing data that better reflects their own experiences and outcomes.

Can you describe the FARAPULSE PFA platform and discuss the potential benefits and considerations of this technology for patients with AF?
FARAPULSE is Boston Scientific's PFA platform, built around the FARAWAVE™ catheter, which is FDA approved for commercial use. Rather than using heat or freezing to create lesions, PFA delivers brief, high-voltage electrical pulses that induce irreversible electroporation, selectively targeting the myocardial tissue responsible for AF while minimizing injury to surrounding structures.

This tissue selectivity represents an important safety advantage over radiofrequency and cryoballoon ablation by reducing the risk of collateral thermal injury. 

As with any newer technology, we still need long-term outcomes data and a better understanding of how PFA performs across diverse patient populations. REPRESENT-PF will help provide that evidence.

One of the goals of the REPRESENT-PF Registry is to generate meaningful real-world data. From a physician's perspective, how can real-world evidence complement traditional clinical trials and help guide clinical decision-making and patient care?
Randomized clinical trials remain the gold standard for establishing efficacy under controlled conditions, but they often enroll a relatively narrow and unrepresentative patient population. That's precisely the gap REPRESENT-PF is designed to address. Real-world registries allow us to evaluate how technology performs across diverse patients, comorbidities, and practice settings we encounter every day, including many who would not have met the inclusion criteria for a randomized trial.

REPRESENT-PF complements randomized trials by showing how PFA performs in routine clinical practice across diverse patient populations. That broader evidence base can help clinicians make more informed treatment decisions and counsel patients with greater confidence.

Looking ahead, what impact do you hope the REPRESENT-PF Registry will have on patient access and more equitable care across diverse populations?
My hope is that REPRESENT-PF Registry sets a new standard for how cardiovascular studies are designed, with representation built into clinical research from the outset rather than addressed later through small subgroup analyses. Ultimately, our goal is to generate evidence that expands access to care, reduces disparities, and improves outcomes for every patient we serve.