Pulsed-field ablation increased hemolysis compared to thermal ablation but did not significantly increase acute kidney injury risk (3.5% vs 3.1%; RR 1.14; 95% CI 0.42-3.12; p=0.80).
Meta-Analysis (n=5,158)
Does pulsed-field ablation increase hemolysis and acute kidney injury compared to thermal ablation in adults undergoing atrial fibrillation ablation?
Pulsed-field ablation for AF increases intravascular hemolysis compared to thermal ablation but does not increase the risk of acute kidney injury, while reducing major bleeding and procedure time.
Effect estimate: RR 1.14 (95% CI 0.42-3.12)
Absolute Event Rate: 3.5% vs 3.1%
p-value: p=0.80
BACKGROUND Pulsed-field ablation (PFA) is a non-thermal modality for atrial fibrillation (AF) ablation; concerns persist regarding intravascular hemolysis and acute kidney injury (AKI). OBJECTIVE To compare biomarker-defined hemolysis and clinical AKI after PFA versus thermal ablation. METHODS PRISMA-adherent systematic review and random-effects meta-analysis of comparative observational studies in adults undergoing AF ablation. Major databases and trial registries were searched. Risk of bias was assessed with ROBINS-I. Co-primary outcomes were change-from-baseline hemolysis biomarkers (lactate dehydrogenase LDH, haptoglobin, bilirubin) and AKI incidence (preferentially KDIGO-defined). RESULTS Twelve studies (n=5,158; AKI analysis n=4,884; 2,122 PFA, 2,762 thermal) met criteria. Versus thermal ablation, PFA produced significantly greater hemolysis: LDH mean difference (MD) +63.79 U/L (p<0.001); haptoglobin MD -0.30 g/L (p=0.036); bilirubin MD +1.91 μmol/L (p=0.023). AKI risk did not differ (risk ratio RR 1.14, 95% CI 0.42-3.12; p=0.80; absolute rates 3.5% vs 3.1%). PFA was associated with significantly lower major bleeding (RR 0.15, 95% CI 0.04-0.62; p=0.009) and shorter procedure time (MD -25.81 min, 95% CI -49.26 to -2.36; p=0.031). Hemolysis magnitude varied by PFA platform; AKI did not. Limitations include observational designs and heterogeneity. CONCLUSION PFA increases biomarker-defined intravascular hemolysis relative to thermal ablation without increasing population-level AKI. Coupled with reduced major bleeding and enhanced procedural efficiency, these data support PFA use; dose discipline, hydration, and platform selection remain important for high-risk patients.
Kilic et al. (Thu,) conducted a meta-analysis in Atrial fibrillation (n=5,158). Pulsed-field ablation (PFA) vs. Thermal ablation was evaluated on Acute kidney injury (AKI) incidence (RR 1.14, 95% CI 0.42-3.12, p=0.80). Pulsed-field ablation increased hemolysis compared to thermal ablation but did not significantly increase acute kidney injury risk (3.5% vs 3.1%; RR 1.14; 95% CI 0.42-3.12; p=0.80).