Efficacy and safety of Pulsed Field Ablation (PFA) versus Very/High-Power Short Duration Radiofrequency Ablation (v/HPSD RFA) in atrial fibrillation: a systematic review and meta analysis

Abstract Background Pulsed field ablation (PFA) has emerged as a non-thermal strategy for atrial fibrillation (AF) ablation, characterized by myocardial selectivity, rapid lesion formation, and limited collateral injury. In contrast, very/high-power short-duration radiofrequency ablation (v/HPSD RFA) represents the most advanced thermal modality to date. A contemporary comparison of these techniques across clinical and procedural outcomes is essential to inform evolving AF ablation practice. Purpose To rigorously compare PFA with v/HPSD RFA across key clinical and procedural outcomes, with the aim of clarifying their relative strengths and defining their impact on the evolving landscape of atrial fibrillation management. Methods A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. We identified ten studies directly comparing PFA with v/HPSD RFA. Nine studies reported atrial tachyarrhythmia recurrence, five reported redo ablation rates, all ten reported procedural and fluoroscopy times, and four reported left atrial dwell time. Additional safety endpoints evaluating procedural complications were analyzed. Recurrence of atrial tachyarrhythmia was defined as any documented episode of AF, atrial flutter, or tachycardia lasting 30 seconds after a 3-month blanking period. Pooled outcomes were synthesized using fixed- or random-effects models based on heterogeneity and expressed as risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). Results Across nine studies, PFA was associated with significantly lower atrial tachyarrhythmia recurrence than v/HPSD RFA (RR 0.81; 95% CI 0.69–0.69; p=0.01; I²=0%). Among the five studies evaluating redo ablation, rates were statistically comparable, however non-significant, showing trends favoring PFA (RR 0.93; 95% CI 0.83–1.03; p=1.03). In all ten studies assessing procedural efficiency, PFA produced markedly shorter procedures (MD –35.97 mins; p0.00001) but longer fluoroscopy time (MD 7.78 mins; p=0.001) possibly due to fluoroscopic guidance in device positioning and confirmation of antral contact. For left atrial dwell time, PFA achieved notable reductions (MD –33.25 mins; p0.0001). Safety outcomes, including overall and individual complications were comparable between modalities, with uniformly low event rates. Funnel plot analysis showed no evidence of publication bias. Conclusion PFA was associated with lower atrial tachyarrhythmia recurrence and a trend toward fewer redo ablations. It also conferred superior overall procedural efficiency and reduced left atrial dwell time. Although fluoroscopy time was longer, reflecting contemporary catheter architecture and evolving operator familiarity, its safety profile remained comparable to v/HPSD RFA. These findings position PFA as a highly effective and durable ablation modality, with the potential to further refine first-line strategies as long-term randomized evidence continues to evolve.Atrial Tachyarrhythmia Recurrence & RedoProcedural Efficiency