Pulsed Field Ablation Versus High-Power Short-Duration Ablation for Atrial Fibrillation—A Meta-Analysis of Reconstructed Time-to-Event Data

Background: Pulsed field ablation (PFA) has shown promising results for atrial fibrillation (AF), with efficacy comparable to established ablation techniques. High-power short-duration (HPSD) ablation has also emerged as a potential alternative. However, the relative superiority between these approaches remains uncertain. We performed a systematic review and meta-analysis to address this gap. Methods: Three databases were searched. The primary outcome was freedom from AF recurrence. Secondary outcomes included tamponade and other complications, procedure and fluoroscopy durations. Time-to-event data were reconstructed, and a random-effects model was employed. Given variability in post-ablation blanking periods across studies, landmark analyses were performed using a 3-month cut-off to account for the potential under-detection of early recurrence events. Results: Eight studies (1369 patients [PFA: 642; HPSD: 727]) were included. PFA was associated with greater freedom from AF recurrence (HR 0.751; 95% CI 0.57 to 0.99; p = 0.044). Landmark analyses showed no difference in the 0–3 month period; a significant benefit of PFA was observed thereafter (HR 0.72; 95% CI 0.54 to 0.98; p = 0.033). There were no significant differences between groups in the incidence of tamponade (p = 0.73) or overall complications (p = 0.99). PFA was associated with shorter procedure duration (MD 37.05; 95% CI 27.69 to 46.41; p < 0.01), whereas fluoroscopy duration was significantly shorter in the HPSD group (MD −9.04; 95% CI −11.71 to −6.37; p < 0.001). Conclusion: PFA was associated with a lower risk of AF recurrence compared to HPSD, particularly beyond the late post-ablation period, with similar rates of complications. Although PFA was associated with shorter procedure duration, HPSD demonstrated reduced fluoroscopy time.