Pulsed Field Ablation Versus Thermal Ablation in Paroxysmal Atrial Fibrillation

Background: Pulsed field ablation has emerged as a non-thermal alternative to radiofrequency and cryoballoon ablation for treatment of paroxysmal atrial fibrillation. Research Question/Hypothesis: We hypothesized that pulsed field ablation would provide comparable efficacy and safety to radiofrequency and cryoballoon ablation. Methods: A systematic review and frequentist random-effects network meta-analysis of randomized controlled trials enrolling exclusively patients with paroxysmal atrial fibrillation was performed. Outcomes included 12-month recurrence or treatment failure, major complications, procedural time, and fluoroscopy time. Odds ratios and mean differences with 95% confidence intervals were calculated. Results: Nine randomized trials involving 2,531 patients were included. No significant differences were observed for 12-month recurrence or treatment failure. Compared with pulsed field ablation, the odds ratio was 1.13 (95% confidence interval, 0.79-1.62) for cryoballoon ablation and 1.24 (95% confidence interval, 0.89-1.72) for radiofrequency ablation. Major complications were similar (odds ratio 1.42 for cryoballoon ablation and 1.63 for radiofrequency ablation versus pulsed field ablation). Procedural time was longer with radiofrequency ablation than pulsed field ablation (mean difference 26.98 minutes, 95% confidence interval, 2.88-51.08), whereas no significant difference was observed between cryoballoon and pulsed field ablation (mean difference 2.00 minutes, 95% confidence interval, –29.02 to 33.02). Fluoroscopy time was lower with cryoballoon ablation (mean difference –9.06 minutes, 95% confidence interval, –17.84 to –0.28) and radiofrequency ablation (mean difference –11.29 minutes, 95% confidence interval, –18.41 to –4.16) compared with pulsed field ablation. Conclusions: Among patients with paroxysmal atrial fibrillation, pulsed field, radiofrequency, and cryoballoon ablation demonstrated comparable efficacy and safety. Pulsed field ablation was associated with shorter procedural duration than radiofrequency ablation, although fluoroscopy times remained higher. These findings support pulsed field ablation as an effective alternative to established thermal ablation technologies.