One-year clinical outcomes after dual-energy ablation for atrial fibrillation: a systematic review and meta-analysis

Background Dual-energy ablation combining radiofrequency (RF) and pulsed-field ablation (PFA) has been proposed as a next-generation approach for atrial fibrillation (AF) therapy, aiming to combine lesion durability with myocardial selectivity and procedural safety. While early feasibility studies have demonstrated the acute success, the evidence on long-term rhythm outcomes remains limited. Purpose This meta-analysis aimed to evaluate one-year recurrence rates and clinical outcomes following dual-energy ablation in patients with paroxysmal and persistent AF. Methods A systematic search in Pubmed, Embase and Cochrane databases, identified four prospective studies that reported one-year follow-up after dual-energy ablation. The primary outcome was recurrence of atrial arrhythmias (AF, atrial flutter, or atrial tachycardia) at 1 year follow-up after a 90-day blanking period. Secondary endpoints included specific recurrence of AF, atrial flutter/tachycardia, redo procedures, and cardiovascular-related hospitalizations. Pooled single-arm proportions were calculated using a random-effects model with Freeman-Tukey double-arcsine transformation (R meta package). Results A total of 558 patients were included, with a median age of 64.9 ± 9.4 years; 358 (64.2%) were male, 337 (60.4%) had persistent AF, and 221 (39.6%) paroxysmal AF. At one year, the pooled rate of atrial tachyarrhythmia recurrence was 17.2% (95% CI 7.2 to 30.2; I² = 92%), corresponding to 82.8% freedom from arrhythmia (Figure 1A). The pooled AF recurrence rate was 15.3% (95% CI 2.6 to 35.3; I² = 93%) (Figure 1B), while atrial flutter/tachycardia recurrence occurred in 3.4% (95% CI 1.4 to 6.0; I² = 0%) (Figure 1C). Redo ablation was required in 6.0% (95% CI 1.5-13.2; I² = 85%), and cardiovascular-related hospitalizations were reported in 3.8% (95% CI 0.1 to 11.6; I² = 89%) (Figure 2). Across all studies, no atrio-esophageal fistula, stroke, or procedure-related death occurred during follow-up. Quality-of-life improvement, expressed by AFEQT score gain, ranged between +17 and +25 points, indicating significant symptomatic benefit. Conclusion In our analysis, dual-energy ablation was associated with a one-year arrhythmia-free survival of approximately 80%, with low redo and cardiovascular hospitalization rates. The improvement in quality-of-life scores and absence of major adverse events suggest favorable mid-term outcomes with the hybrid-energy approach. While encouraging, these findings are derived from single-arm studies, and randomized comparisons with single-energy PFA and RF are needed to confirm long-term efficacy and durability.