Pulsed Field or Cryoballoon Pulmonary Vein Isolation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction

Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) frequently coexist, worsening prognosis. While catheter ablation confers clinical benefits in this high-risk population, comparative data between novel non-thermal pulsed field ablation (PFA) and established cryoballoon ablation (CBA) for AF-therapy in patients with HFrEF are limited. To compare the efficacy and safety of PFA- with CBA-based pulmonary vein isolation (PVI) in patients with AF and HFrEF (left ventricular ejection fraction ≤40%). This retrospective, international multicenter study included patients with HFrEF undergoing first-time PVI-only procedures between 2018 and 2025. Propensity-score matching (1:1 ratio) was applied to balance baseline characteristics. The primary efficacy endpoint was the first recurrence of any atrial tachyarrhythmia after a 3-month blanking period. Secondary measures included safety events and procedural efficiency. A total of 700 patients from 12 German and Canadian centers were included, with 420 patients analyzed following propensity-score matching. At 12 months, freedom from atrial tachyarrhythmia recurrence with PFA was comparable to CBA (Kaplan-Meier estimates, 65.0% vs. 67.8%; hazard ratio, 1.09; 95% CI, 0.77 to 1.55; P=0.61). No statistically significant differences in observed safety outcomes were detected. PFA significantly improved procedural efficiency with shorter total procedure duration (58±22min vs. 72±22min; P<0.001), left-atrial dwell time (42±16min vs. 52±17min; P<0.001) and lower contrast dye use (0 ml [IQR 0-15] vs. 47 ml [IQR 30-56], P<0.001). In patients with AF and HFrEF, PFA-based PVI achieves similar rhythm-control efficacy and safety compared with CBA, while significantly enhancing procedural efficiency.