Key result
PFA cuts arrhythmia recurrence ~22% vs. thermal ablation at 12 months.
Why the study?
Pulsed-field ablation has emerged as an alternative to thermal ablation for pulmonary vein isolation, but its efficacy and safety in first-time procedures needed systematic evaluation.
Does pulsed-field ablation reduce atrial tachyarrhythmia recurrence in patients with atrial fibrillation undergoing first-time pulmonary vein isolation compared to thermal ablation?
Meta-Analysis (n=8,546)
Yes
Does pulsed-field ablation reduce atrial tachyarrhythmia recurrence in patients with atrial fibrillation undergoing first-time pulmonary vein isolation compared to thermal ablation?
Hazard Ratio: 1.28 (95% CI 1.1–1.48)
Absolute Event Rate: 78.4% vs 73.4%
p-value: p=0.001
In patients undergoing first-time pulmonary vein isolation for atrial fibrillation, pulsed-field ablation significantly reduced the risk of atrial tachyarrhythmia recurrence and shortened procedure times compared to thermal ablation, with a lower risk of transient phrenic nerve palsy.
PFA may reduce atrial tachyarrhythmia recurrence after first PVI; extends meta-analytic evidence versus thermal ablation but needs randomized confirmation.
Background With over 60 million cases worldwide, atrial fibrillation (AF) is one of the most common cardiac arrhythmias in adults. Pulsed‐field ablation (PFA) has emerged as a significant alternative to thermal ablation for pulmonary vein isolation (PVI). This systematic review and meta‐analysis investigated the efficacy and safety of PFA versus thermal ablation in patients undergoing first‐time PVI. Methods We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library from inception to 2025. Hazard ratios (HRs) with 95% confidence intervals (CIs) were derived from reconstructed Kaplan–Meier survival curves to compare atrial tachyarrhythmia recurrence between PFA and thermal ablation. Random‐effects models were used to compare AF recurrence, durable PVI, redo procedures, phrenic nerve palsy (PNP), and other safety outcomes between the two groups. Results A total of 27 studies comprising 8546 patients were included. Kaplan–Meier reconstruction from ten studies demonstrated higher 12‐month arrhythmia‐free survival with PFA compared with thermal ablation (78.4% [95% CI, 76.1–80.8] vs. 73.4% [95% CI, 71.5–75.4]). Thermal ablation was associated with a significantly higher risk of atrial tachyarrhythmia recurrence (HR 1.28, 95% CI 1.10–1.48; p = 0.001). Subgroup analyses demonstrated that PFA significantly reduced the recurrence risk in patients with paroxysmal AF (HR 1.63, 95% CI 1.31–2.03; p < 0.001), whereas no significant difference was observed in those with persistent AF (HR 1.13, 95% CI 0.92–1.41; p = 0.25). Conclusions PFA was associated with lower rates of atrial tachyarrhythmia and AF recurrence rates than thermal ablation in patients undergoing first‐time PVI; however, these findings should be interpreted cautiously, given the predominance of observational studies.
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Alnomani et al. (2026) conducted a meta-analysis in Atrial fibrillation (n=8,546). Pulsed-field ablation vs. Thermal ablation was evaluated on 12-month arrhythmia-free survival (HR 1.28, 95% CI 1.10-1.48, p=0.001). Pulsed-field ablation significantly improved 12-month arrhythmia-free survival to 78.4% compared to 73.4% with thermal ablation, corresponding to a higher risk of recurrence with thermal ablation (HR 1.28).
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