Autonomic Profile Changes after Pulsed‐Field versus Thermal Ablation in Patients with Atrial Fibrillation: A Systematic Review and Meta‐Analysis

Background Catheter ablation is an established therapy for atrial fibrillation (AF), with thermal ablation as a standard modality. Pulsed‐field ablation (PFA) is a nonthermal alternative that selectively ablates myocardium while sparing collateral tissue. Its comparative autonomic impact relative to thermal ablation remains unclear. The study aims to compare autonomic changes following PFA and thermal ablation in AF patients, focusing on heart rate (HR), heart rate variability (HRV), bradyarrhythmias, and arrhythmia recurrence. Methods We systematically searched MEDLINE, EMBASE, and Cochrane CENTRAL through August 2025 for randomized and nonrandomized studies reporting pre‐ and post‐ablation HR or HRV. Data were pooled using random‐effects or fixed‐effects models, depending on the presence of heterogeneity. Results Six studies (800 patients, PFA: 407, thermal: 393) were included. Thermal ablation was associated with a significantly greater rise in resting HR compared with PFA (mean difference ‐7.57 bpm, 95%CI: ‐11.66‐3.48, p = 0.0003; I 2 = 90% indicating high heterogeneity). HRV indices were consistently better preserved after PFA. SDNN at 12 months was approximately 150 ms with PFA versus 115 ms with thermal ablation (p<0.001 in one study). The overall incidence of bradyarrhythmias did not differ significantly, though transient intraprocedural bradycardia was more frequently observed with PFA. Arrhythmia recurrence rates were comparable between groups (OR 0.96, 95% CI 0.47‐1.99, p = 0.92; I 2 = 0%). Acute pulmonary vein isolation was achieved in >95% of patients. Conclusions PFA attenuates autonomic perturbation relative to thermal ablation, preserving resting HR and HRV while maintaining comparable arrhythmia outcomes. These findings support PFA as an effective and autonomically sparing strategy for AF ablation.