Pulsed-Field Ablation Versus Thermal Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Pulsed-field ablation (PFA) has emerged as a nonthermal alternative to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) for atrial fibrillation (AF). Randomized evidence has expanded rapidly, but its relative efficacy, procedural performance, and safety across thermal comparators remain uncertain. Methods: We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library from inception through June 30, 2026, for randomized controlled trials comparing PFA with thermal catheter ablation for AF. Random-effects meta-analyses were performed using odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Prespecified subgroup analyses were conducted according to the thermal comparator. Risk of bias was assessed using RoB 2, and certainty of evidence was evaluated using GRADE. Results: Seven randomized controlled trials including 2,076 participants were included. PFA was not associated with a significant reduction in atrial arrhythmia recurrence (OR, 0.83; 95% CI, 0.65–1.07) or repeat ablation (OR, 0.96; 95% CI, 0.55–1.66). PFA significantly reduced total procedure time (MD, −29.85 minutes; 95% CI, −41.03 to −18.66) and left atrial dwell time (MD, −30.95 minutes; 95% CI, −42.89 to −19.01), although heterogeneity was substantial. Phrenic nerve injury did not differ significantly overall (OR, 0.37; 95% CI, 0.12–1.15), and no statistically significant difference was detected in procedure-related adverse events (OR, 0.90; 95% CI, 0.66–1.21). No statistically significant difference was detected in post-blanking class I or III antiarrhythmic drug use (OR, 0.82; 95% CI, 0.58–1.17). Conclusions: No statistically significant differences were detected in rhythm-control or overall safety outcomes, while PFA substantially reduced procedure time and left atrial dwell time. These findings apply mainly to first-time ablation for paroxysmal AF, and precision and certainty were limited for several clinical outcomes.