Cost Comparison of Pulsed Field Ablation and Conventional Thermal Ablation for Atrial Fibrillation: A Systematic Review

BACKGROUND: Pulsed field ablation (PFA) is an emerging non-thermal catheter ablation (CA) modality for the treatment of atrial fibrillation (AF), PFA has shown a relatively similar success rate but offers improved safety compared to thermal approaches such as radiofrequency ablation (RFA) and cryoballoon ablation (Cryo). Although its clinical benefits are well established, comparative data on its economic impact remain limited. OBJECTIVE: This systematic review aimed to compare the cost profiles of PFA versus thermal ablation strategies in patients with AF. METHODS: We systematically searched PubMed, Embase, and Scopus through April 2025 for studies reporting cost analyses comparing PFA with RFA or Cryo. Extracted data included per-patient cost, procedural time, and, when available, cost-effectiveness metrics such as quality-adjusted life years (QALYs) and net monetary benefit (NMB). RESULTS: Four studies met the inclusion criteria. Despite variability in health care settings and costing approaches, three of the four studies demonstrated that PFA was cost-saving compared to thermal ablation, with per-patient differences ranging from 520 to 2387. One study reported higher costs for PFA, with an excess of 2447 compared to Cryo. PFA was consistently associated with shorter procedural times, suggesting potential efficiency gains for high-volume centers. Only one study reported a formal cost-effectiveness analysis, in which PFA demonstrated both lower total costs and higher QALYs, resulting in an NMB of 2947 at a willingness-to-pay threshold of 100, 000 per QALY. CONCLUSION: PFA shows a favorable cost profile compared to RFA and Cryo, driven by reduced procedural time and lower long-term costs.