Dual-energy versus PFA for catheter ablation treatment of patients with persistent atrial fibrillation: a systematic review and meta-analysis

Background Although pulsed-field ablation (PFA) has rapidly emerged as a safe and efficient energy source for atrial fibrillation (AF) ablation, its long-term efficacy - particularly in patients with persistent AF - remains uncertain. Dual-energy (DE) systems combining radiofrequency (RF) and PFA were developed to address these limitations by allowing targeted hybrid energy delivery during one procedure. Comparative clinical data between DE and single-energy PFA platforms are still limited. Purpose This study aims to compare the acute and one-year outcomes of DE versus PFA-only ablation in persistent AF. Methods A comprehensive search of PubMed, Embase, and Cochrane databases was conducted. The primary endpoint was acute pulmonary vein isolation (PVI) success. Secondary endpoints included major procedural complications, atrial tachyarrhythmia recurrence, and cardiovascular hospitalizations. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using the Mantel-Haenszel random-effects model with restricted maximum likelihood variance estimation; heterogeneity was assessed by I² statistics. Results Three studies were included, enrolling 331 DE and 395 PFA patients. The mean age was 64.4 ± 10.1 vs 64.3 ± 9.6 years, with 66.4% vs 70.1% men, respectively. Persistent AF was present in 81% of DE and 84% of PFA cohorts. The median follow-up was 12 months. Acute PVI was successful in 100% of both groups. Across all studies, there were no atrio-esophageal fistulae, complete atrioventricular block, pulmonary vein stenosis, or persistent phrenic nerve injury. Two in-hospital deaths and one tamponade occurred in the DE group, while one myocardial infarction and four pulmonary edema episodes were observed in the PFA group. The pooled OR for major complications was 1.76 (95% CI 0.61 to 5.10; I² = 0%), indicating similar acute safety (Figure 1). At one year, atrial tachyarrhythmia recurrence was numerically lower with DE (17.2% vs 35.3%) but not statistically significant (OR 0.26, 95% CI 0.05 to 1.39; I² = 89.8%). Cardiovascular-related hospitalizations occurred in 3.8% vs 5.1%, respectively (OR 5.95, 95% CI 0.67 to 52.6; I² = 0%) (Figure 2). Conclusion Dual-energy ablation achieves comparable acute success and procedural safety to PFA-only ablation, with a nonsignificant trend toward fewer arrhythmia recurrences at one year. Low rates of complications supports the feasibility of hybrid energy delivery, although randomized trials are required to clarify its long-term advantages in lesion durability and clinical outcomes.