Key result
PFA shows no benefit over thermal ablation for 12-month arrhythmia-free survival in persistent AF.
Why the study?
Large-scale data evaluating the efficacy of pulsed field ablation for pulmonary vein isolation in patients with persistent AF remained limited.
Does pulsed field ablation improve 12-month freedom from atrial arrhythmia recurrence compared to thermal ablation in patients with persistent atrial fibrillation?
Meta-Analysis (n=3,744)
Yes
Does pulsed field ablation improve 12-month freedom from atrial arrhythmia recurrence compared to thermal ablation in patients with persistent atrial fibrillation?
Hazard Ratio: 0.91 (95% CI 0.78–1.07)
In patients with persistent atrial fibrillation, pulsed field ablation provides high 12-month arrhythmia-free survival (72.3%) and low adverse events (<1%), with efficacy comparable to thermal ablation.
Supports pulsed-field ablation as a comparable alternative to thermal ablation in persistent AF; reinforces meta-analytic evidence of similar efficacy and safety.
BACKGROUND AND AIMS: Pulsed field ablation (PFA) has emerged as a non-thermal alternative for pulmonary vein isolation (PVI), offering shorter procedural times and a favorable safety profile for atrial fibrillation (AF) ablation. However, large-scale data evaluating its efficacy in patients with persistent AF remain limited. Our objective was to perform a systematic review and meta-analysis evaluating 12-month atrial arrhythmia recurrence following PFA in patients with persistent AF. METHODS: A systematic search of MEDLINE, Embase, Scopus, LILACS, and Cochrane databases was performed. Studies including patients with persistent AF undergoing first-time PVI with PFA and reporting 12-month arrhythmia-free survival were included. When available, outcomes were compared with thermal ablation using time-to-event analyses. Random-effects models were used. Exploratory meta-regression analyses were conducted to assess potential sources of heterogeneity. RESULTS: Among 1699 screened studies, 26 met the inclusion criteria, comprising 3744 patients with persistent AF treated with PFA. The pooled 12-month freedom from atrial arrhythmia recurrence was 72.3% (95% CI, 69.0-75.5), with substantial heterogeneity (I² = 74.4%). Eight studies (31%) included a thermal comparator; pooled time-to-event analysis demonstrated no significant difference between PFA and thermal ablation (HR, 0.91 [95% CI, 0.78-1.07]). Exploratory meta-regression did not identify significant effect modification by baseline characteristics, lesion-set strategy, rhythm monitoring intensity, or year of publication. Ablation-related adverse events occurred in < 1% of cases for both energy sources. CONCLUSION: In patients with persistent AF, PFA is associated with a high arrhythmia-free survival at 12 months and low rates of ablation-related adverse events. Comparative findings versus thermal ablation should be considered exploratory and interpreted cautiously, given the limited and heterogeneous comparator data.
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Villarreal et al. (2026) conducted a meta-analysis in Persistent atrial fibrillation (n=3,744). Pulsed field ablation vs. Thermal ablation was evaluated on 12-month freedom from atrial arrhythmia recurrence (HR 0.91, 95% CI 0.78-1.07). Pulsed field ablation yielded 72.3% 12-month arrhythmia-free survival in persistent AF, with no significant difference compared to thermal ablation (HR 0.91; 95% CI 0.78-1.07).
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