Pulsed field ablation versus conventional thermal ablation for atrial fibrillation: a systematic review and meta-analysis

Introduction Pulsed field ablation (PFA) is a non-thermal alternative to conventional thermal ablation, including radiofrequency and cryoablation, for the treatment of atrial fibrillation (AF). It delivers high-voltage, ultra-short electrical fields in the microsecond range, inducing irreversible electroporation with greater myocardial selectivity. This enables effective lesion formation while minimising thermal injury to adjacent structures such as the oesophagus and phrenic nerve. PFA has therefore emerged as a potentially safer strategy, maintaining pulmonary vein isolation efficacy while reducing thermal-related adverse events. However, despite growing clinical adoption, comparative evidence between PFA and conventional thermal ablation remains heterogeneous. Purpose To assess the efficacy and safety of PFA compared with conventional thermal ablation in AF, focusing on atrial arrhythmia recurrence and complications including oesophageal injury, phrenic nerve palsy and cardiac tamponade. Methods A systematic review and meta-analysis based on the PICOt framework included patients with AF undergoing pulmonary vein isolation, comparing PFA with conventional thermal ablation. Efficacy and safety outcomes were analysed using R software and the meta package. Dichotomous outcomes were expressed as relative risk (RR) with 95% confidence intervals (CI) and pooled using the Mantel–Haenszel method with a random-effects model (DerSimonian–Laird). Heterogeneity was assessed using Cochran’s Q test and the I² statistic. Statistical significance was defined as p < 0.05. Results The systematic search identified 330 records (PubMed: 87; EMBASE: 243). After screening and eligibility assessment, 6 randomised controlled trials (RCTs) were included (n = 2,110; PFA: 1,059; thermal: 1,051). Devices included Farapulse, PulseSelect and Varipulse versus radiofrequency or cryoablation, with emphasis on the ADVENT, Sphere Per-AF and BEAT-PAROX-AF trials. PFA demonstrated superior maintenance of sinus rhythm compared with thermal ablation (RR 1.07; 95% CI 1.01–1.13; p = 0.012), with no heterogeneity (I² = 0%). No significant differences were observed in overall adverse events (RR 0.95; 95% CI 0.87–1.05; p = 0.50) or major complications, including oesophageal injury and cardiac tamponade (RR 0.59; 95% CI 0.26–1.37; p = 0.52). Conclusions Although both techniques show comparable safety profiles, PFA is associated with higher clinical efficacy in AF treatment. These findings support the progressive incorporation of PFA into clinical practice as a promising strategy to optimise rhythm control without increasing clinically relevant complications. Further studies with long-term follow-up are required to confirm sustained clinical benefit.Efficacy of PFA vs. Thermal AblationAdverse Events: PFA vs.