Comparative Efficacy and Safety of Pulsed Field Ablation and Conventional Thermal Ablation for Atrial Fibrillation: A GRADE assessed Systematic Review and Meta analysis of Randomized Controlled Trials

Background Pulsed field ablation (PFA) is a nonthermal alternative to conventional thermal ablation (TA) for atrial fibrillation (AF), but comparative certainty across outcomes remains variable. Methods We systematically reviewed randomized controlled trials comparing PFA with radiofrequency or cryoballoon ablation. Primary analyses were restricted to paroxysmal AF; exploratory analyses incorporated trials enrolling persistent or mixed AF populations. Random-effects meta-analyses evaluated efficacy, safety, quality of life, and procedural outcomes, with certainty assessed using GRADE. Results Four RCTs (1,393 participants) contributed to the primary analyses. PFA did not differ from TA in atrial arrhythmia recurrence (RR 1.00, 95% CI 0.67–1.49) or single-procedure success (RR 1.04, 95% CI 0.92–1.17). Serious adverse events were also similar (RR 0.94, 95% CI 0.71–1.25). PFA significantly reduced skin-to-skin procedural time (MD −17.04 minutes, 95% CI −20.84 to −13.23). Exploratory analyses incorporating two additional RCTs generally supported these findings, including similar recurrence (RR 0.95, 95% CI 0.78–1.16) and single-procedure success (RR 1.06, 95% CI 0.99–1.13). Certainty ranged from moderate to very low across outcomes, with risk of bias, imprecision, and inconsistency contributing to downgrading. Conclusion PFA provides similar rhythm efficacy and overall safety to contemporary TA while reducing selected procedural times. However, confidence in individual estimates varies, particularly for rare complications and exploratory procedural outcomes. Further randomized evidence with longer follow-up is needed.