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Introduction <p>Pulsed-field ablation (PFA) has demonstrated promising efficacy and safety for atrial fibrillation ablation. However, significant gaps remain regarding its overall performance and long-term outcomes when compared to thermal ablation.</p> Methods <p>We systematically searched Pubmed, Embase and Cochrane Central for studies comparing PFA and thermal ablation for pulmonary vein isolation in patients with paroxysmal or persistent atrial fibrillation reporting at least one outcome of interest. We used risk ratio (RR) with 95% confidence intervals (CIs) as the effect size measure for binary outcomes, Mean Differences (MD) with 95% confidence intervals were used for continuous outcomes, employing a random-effects model. We incorporated comprehensive sub-group and Kaplan-Meier survival analyses.</p> Results <p>We included 22 studies (<i>n</i> = 6,056) including 3 RCTs. PFA demonstrated a lower risk of acute treatment failure compared to thermal ablation (RR: 0.85; 95%CI: 0.75–0.96), with no subgroup difference noted in the RCT subgroup (RR: 0.84; 95% CI: 0.67–1.06). PFA also achieved higher likelihood of achieving first pass isolation (RR: 1.15; 95% CI: 1.02–1.29), while significantly decreasing overall procedure duration (MD: -22.96&#xa0;min; 95% CI: -30.35 to -15.58) but increasing fluoroscopy time (MD: 3.89&#xa0;min; 95% CI: 5.97 to 1.81). In terms of safety, PFA significantly reduced the risk of periesophageal injuries (RR: 0.29; 95% CI: 0.12–0.69) and phrenic nerve palsy (RR: 0.27; 95% CI: 0.12–0.62), but a higher risk of cardiac tamponade (RR: 2.37; 95% CI: 1.17–4.82). No significant differences were observed in bleeding, mortality, systemic embolic events, or vascular complications.</p> Conclusion <p>Our updated analysis demonstrates that PFA is a promising alternative to traditional thermal ablation techniques for atrial fibrillation, offering improved procedural efficiency and a favorable safety profile, particularly with lower periesophageal injury.</p> Graphical Abstract <p></p>

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Pulsed-field ablation versus thermal ablation for atrial fibrillation: an updated systematic review and meta -analysis of randomized controlled trials and observational studies with time-to-event analysis

  • 期刊论文

  • 发表日期：

    2026年3月30日

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  • Zainab Humayun,
  • Mir Wajid Majeed,
  • Dhruvi Kalpesh Joshi,
  • Ayesha Ayesha,
  • Mariano Gallo Ruelas,
  • Leo Consoli,
  • Omar Baqal,
  • Muhammad Arham,
  • Shariq Ahmad Wani,
  • Bazil Azeem,
  • Muhammad Abdullah Naveed,
  • Ahila Ali,
  • Barbara Reis Silva,
  • Ahmad Kofahi,
  • Muhammad Bilal Munir,
  • Christopher V. DeSimone,
  • Justin Z. Lee,
  • Talal Asif

摘要

Introduction

Pulsed-field ablation (PFA) has demonstrated promising efficacy and safety for atrial fibrillation ablation. However, significant gaps remain regarding its overall performance and long-term outcomes when compared to thermal ablation.

Methods

We systematically searched Pubmed, Embase and Cochrane Central for studies comparing PFA and thermal ablation for pulmonary vein isolation in patients with paroxysmal or persistent atrial fibrillation reporting at least one outcome of interest. We used risk ratio (RR) with 95% confidence intervals (CIs) as the effect size measure for binary outcomes, Mean Differences (MD) with 95% confidence intervals were used for continuous outcomes, employing a random-effects model. We incorporated comprehensive sub-group and Kaplan-Meier survival analyses.

Results

We included 22 studies (n = 6,056) including 3 RCTs. PFA demonstrated a lower risk of acute treatment failure compared to thermal ablation (RR: 0.85; 95%CI: 0.75–0.96), with no subgroup difference noted in the RCT subgroup (RR: 0.84; 95% CI: 0.67–1.06). PFA also achieved higher likelihood of achieving first pass isolation (RR: 1.15; 95% CI: 1.02–1.29), while significantly decreasing overall procedure duration (MD: -22.96 min; 95% CI: -30.35 to -15.58) but increasing fluoroscopy time (MD: 3.89 min; 95% CI: 5.97 to 1.81). In terms of safety, PFA significantly reduced the risk of periesophageal injuries (RR: 0.29; 95% CI: 0.12–0.69) and phrenic nerve palsy (RR: 0.27; 95% CI: 0.12–0.62), but a higher risk of cardiac tamponade (RR: 2.37; 95% CI: 1.17–4.82). No significant differences were observed in bleeding, mortality, systemic embolic events, or vascular complications.

Conclusion

Our updated analysis demonstrates that PFA is a promising alternative to traditional thermal ablation techniques for atrial fibrillation, offering improved procedural efficiency and a favorable safety profile, particularly with lower periesophageal injury.

Graphical Abstract