Delayed myocardial injury and reduced inflammation after pulsed-field vs. cryoballoon vs. radiofrequency ablation for atrial fibrillation

Background Conventional thermal atrial fibrillation (AF) ablation (radiofrequency or cryoballoon) induces immediate coagulation necrosis and can augment early postoperative inflammatory responses. Pulsed-field ablation (PFA) is a non-thermal modality based on irreversible electroporation; experimental and histopathological studies suggest a distinct injury profile that may influence the timing of biomarker release and the early inflammatory footprint after pulmonary vein isolation (PVI). 1,2 Purpose To compare early postoperative inflammation and myocardial injury after first-time PVI performed with PFA, cryoballoon ablation (CBA), or radiofrequency ablation (RFA). Methods Single-centre retrospective analysis of consecutive patients undergoing first-time AF ablation with PVI only (no additional substrate modification) between April 2024 and April 2025. We collected venous blood samples to assess high-sensitivity C-reactive protein (hs-CRP) at three time points (baseline, 30 minutes post-procedure, and the next morning [Day 1]) and creatine kinase (CK) and creatine kinase MB isoform (CK-MB) at four time points (baseline, 30 minutes post-procedure, 6 hours post-procedure, and the next morning [Day 1]). The hs-CRP levels were considered as a surrogate for systemic inflammation, whereas the CK-MB levels served as a marker of myocardial injury. Data are presented as median [IQR]. Overall group differences were evaluated using Kruskal–Wallis tests. Results We retrospectively analysed 130 consecutive patients (PFA n=61; CBA n=15; RFA n=54). Baseline characteristics were similar among the three groups. CK-MB dynamics revealed different temporal patterns among the three energy sources. In the CBA group, the CK-MB levels increased 30 minutes after the ablation procedure. Conversely, in the PFA group, the peak values were observed at 6 hours post-ablation. The CK-MB levels at 30 minutes were significantly lower in the PFA group than in the CBA group (PFA group vs. CBA group, 25.0 [16.5-41.0] vs. 64.0 [41.0-95.0] U/L, p < 0.001). However, the CK-MB levels remained elevated and were similar between the groups on Day 1. The CK-MB levels remained consistently lower in the RFA group across all measured time points. The hs-CRP levels on Day 1 were significantly lower in the PFA group than in the CBA group (PFA group vs. CBA group, 0.47[0.23-0.58] vs. 0.83[0.55-1.21] mg/dL, p=0.05). Conclusion These findings support the hypothesis that PFA causes delayed myocardial injury and less acute systemic inflammation than CBA, consistent with the apoptosis-based mechanism. 1,2 In RFA, the lesion set is typically more linear than in CBA or PFA, which may partly explain the lower levels of myocardial enzyme release observed in the RFA group.Time course of CK, CKMB and CRP