Key result
PFA reduces AF burden by an additional ~0.8% versus RFA and cryoballoon ablation.
Why the study?
The relative advantages and limitations of currently available catheter ablation energy modalities for AF remain incompletely understood despite the emergence of pulsed field ablation.
Do contemporary catheter ablation modalities (PFA, CBA, LBA, LTD) improve efficacy, procedural efficiency, or safety compared to radiofrequency ablation in patients with atrial fibrillation?
Meta-Analysis (n=7,226)
Do contemporary catheter ablation modalities (PFA, CBA, LBA, LTD) improve efficacy, procedural efficiency, or safety compared to radiofrequency ablation in patients with atrial fibrillation?
Contemporary catheter ablation modalities for atrial fibrillation offer broadly comparable efficacy and safety, though pulsed field ablation provides greater AF burden reduction and superior procedural efficiency compared to radiofrequency and cryoballoon ablation.
Supports PFA for greater AF burden reduction despite similar recurrence; extends RCT network evidence on ablation endpoints.
BACKGROUND: Pulsed field ablation (PFA) has reshaped atrial fibrillation (AF) ablation landscape, yet the relative advantages and limitations of currently available catheter ablation energy modalities-radiofrequency ablation (RFA), cryoballoon ablation (CBA), laserballoon ablation (LBA), PFA, and lattice-tip dual-energy (LTD) ablation-remain incompletely understood. OBJECTIVE: To compare the efficacy, procedural efficiency, and safety of catheter ablation modalities for AF. METHODS: MEDLINE, Scopus, and the Cochrane Library were searched through March 15, 2026. Comparative effects across 5 ablation energy modalities were synthesized using random-effects network meta-analysis. RESULTS: Thirty-two randomized controlled trials (7,226 patients) were analyzed. No significant differences were observed among modalities for atrial tachyarrhythmia recurrence, repeat ablation, cardioversion, or patient-reported outcomes. PFA showed greater AF burden reduction compared to RFA (mean difference [MD] -0.78%, 95% confidence interval [CI] -0.91% to -0.65%) and CBA (MD -0.90%, 95% CI -1.01% to -0.79%). PFA was associated with lower hospitalization risk than RFA in the primary frequentist analysis (RR 0.34, 95% CI 0.12-0.95), whereas Bayesian sensitivity analysis showed no significant differences across modalities. Both PFA and CBA were associated with shorter total procedure duration and left atrial dwell time than RFA, whereas fluoroscopy time was shortest with RFA. Safety profiles were broadly comparable, although CBA and LBA were associated with a higher risk of persistent phrenic nerve injury than RFA. CONCLUSION: Contemporary catheter ablation modalities demonstrated broadly comparable efficacy and safety for AF. PFA was associated with greater AF burden reduction and superior procedural efficiency, whereas the observed hospitalization benefit was not confirmed in Bayesian sensitivity analysis and warrants cautious interpretation.
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Karakasis et al. (2026) conducted a meta-analysis in Atrial fibrillation (n=7,226). Pulsed field ablation (PFA) vs. Radiofrequency ablation (RFA) and other modalities was evaluated on Atrial fibrillation burden reduction (PFA vs RFA) (MD -0.78%, 95% CI -0.91% to -0.65%). Pulsed field ablation showed greater atrial fibrillation burden reduction compared to radiofrequency ablation (MD -0.78%; 95% CI -0.91% to -0.65%) and cryoballoon ablation.
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