Comparative efficacy and safety of pulsed field ablation versus cryoballoon ablation in atrial fibrillation: A meta-analysis of mid- and long-term outcomes

Background: Pulsed field ablation (PFA) is an emerging non-thermal modality for pulmonary vein isolation (PVI) in atrial fibrillation (AF), offering enhanced tissue selectivity and reduced collateral damage compared to cryoballoon ablation (CBA). Objective: -analysis compares the mid- to long-term efficacy, safety, and procedural characteristics of PFA versus CBA in AF treatment. Methods: A systematic search of PubMed, EMBASE, and the Cochrane Library through July 2025 identified nine comparative studies involving 2,718 patients (1,381 PFA; 1,337 CBA). Pooled risk ratios (RRs) and mean differences (MDs) were calculated using random-effects models, with subgroup analyses for paroxysmal and persistent AF. Results: PFA showed a trend toward lower recurrence rates (RR = 0.86, 95 % CI: 0.70-1.04), particularly in paroxysmal AF (RR = 0.83, 95 % CI: 0.68-1.01), while outcomes in persistent AF were comparable (RR = 0.98, 95 % CI: 0.69-1.38). Procedure time was significantly shorter with PFA (MD = -9.59 min, 95 % CI: -17.80 to -1.37), whereas fluoroscopy duration showed no significant difference. Safety analysis revealed a non-significant trend favoring PFA (RR = 0.75, 95 % CI: 0.49-1.14), with fewer cases of phrenic nerve injury and cardiac tamponade. Conclusion: PFA and CBA demonstrate comparable efficacy and safety in AF ablation. PFA may offer procedural advantages and improved outcomes in paroxysmal AF, supporting its expanding role in clinical practice. Further randomized trials are warranted to validate these findings and guide optimal treatment strategies.