Pulsed field ablation versus thermal ablation for paroxysmal atrial fibrillation: a systematic review and meta-analysis

Background Pulsed field ablation (PFA) is a novel non-thermal ablation modality that may reduce collateral tissue injury compared with conventional thermal ablation. We compared the efficacy, safety, and procedural outcomes of PFA versus thermal ablation in patients with paroxysmal atrial fibrillation (PAF). Methods We conducted a PRISMA-compliant systematic review and meta-analysis registered in PROSPERO (CRD420261321642). PubMed, Embase, Scopus, MEDLINE, and the Cochrane Library were searched through February 2026. The primary outcome was freedom from atrial arrhythmia at 12 months. Secondary outcomes included freedom from arrhythmia off antiarrhythmic drugs (AADs), procedural complications, and procedural metrics. Random-effects models were used to calculate pooled risk ratios (RR) and mean differences (MD). Results Twenty-three studies comprising 5755 patients (2266 PFA; 3489 thermal ablation) were included. PFA was associated with higher freedom from atrial arrhythmia (RR 1.07, 95% CI 1.04–1.11; p < 0.0001; I 2 = 14.8%) and greater off-AAD success (RR 1.07, 95% CI 1.02–1.12; p = 0.0089). Overall complication rates were similar (RR 0.69, 95% CI 0.47–1.02), with favorable trends toward lower esophageal injury (RR 0.56) and phrenic nerve injury (RR 0.55). Rates of stroke, transient ischemic attack, major bleeding, and cardiac tamponade were comparable. PFA was associated with shorter procedures and reduced fluoroscopy exposure. Conclusions PFA demonstrated modestly improved efficacy in pooled analyses, although randomized trials showed efficacy comparable to thermal ablation. PFA also showed favorable safety trends and improved procedural efficiency, supporting its role as a promising strategy for PAF while highlighting the need for additional long-term randomized studies.