Pulsed field versus conventional thermal ablation for paroxysmal atrial fibrillation: Insights from a reconstructed individual patient data meta-analysis of randomised controlled trials

Background Previous meta-analyses of randomised controlled trials (RCTs) demonstrated that pulsed field ablation (PFA) has an acceptable safety profile, with shorter procedural times, compared to conventional thermal ablation for atrial fibrillation (AF). However, the efficacy of PFA in reducing the recurrence of atrial tachyarrhythmias remains contentious. Purpose We hypothesised that with the inclusion of the BEAT PAROX-AF trial, an updated meta-analysis of RCTs may show superior procedural success rates with PFA compared to thermal ablation for paroxysmal AF. Methods Three bibliographic databases were searched until February 2026 for RCTs using the pentaspline PFA catheter with published survival curves. Our primary outcome was freedom from procedural failure – defined as a composite of atrial arrhythmia recurrence > 30s after the initial blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation. Individual patient data (IPD) were reconstructed from Kaplan-Meier curves, and log-hazard ratio (HR) transformations were used to preserve time-to-event data using a random effects model. Results We included three RCTs with 1,106 patients. Compared to thermal ablation, PFA significantly reduced procedural failures (HR 0.76; 95% confidence interval [CI] 0.6-0.96; p = 0.02; I2 = 0%; Fig. 1A & B). Total procedure time was shorter with PFA (mean difference [MD] -24.87 min; 95% CI -38.69 to -11.06; p < 0.01; I2 = 93.1%; Fig. 2A), along with left atrial dwell time (MD -25.87 min; 95% CI -38.66 to -13.08; p < 0.01; I2 = 95.5%; Fig. 2B). Fluoroscopy time was non-significantly increased with PFA (MD 3.92 min; 95% CI -0.51 to 8.36; p = 0.08; I2 = 94.8%; Fig. 2C). There was no difference in major complications between groups (risk ratio 0.42; 95% CI 0.1-1.83; p = 0.25; I2 = 68.2%; Fig. 2D). Conclusion In this meta-analysis of RCTs, PFA significantly reduced procedural failures, total procedural durations, and left atrial dwell time. PFA with the pentaspline catheter demonstrates superior clinical efficacy and procedural efficiency compared to conventional thermal ablation for paroxysmal AF.Figure 1.Reconstructed IPD meta-analysisFigure 2.Secondary outcomes