What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Adults with symptomatic atrial fibrillation (paroxysmal or persistent) eligible for pulmonary vein isolation (n=1294). Intervention: Pulsed field ablation (PFA) vs. Conventional thermal ablation (radiofrequency ablation or cryoballoon ablation). Primary outcome: Treatment success rate defined as freedom from recurrent atrial fibrillation beyond 90-day blanking period (RR 1.11, 95% CI 0.87 – 1.42, p=0.20).

What question did this study set out to answer?

This review aims to compare the safety and efficacy of pulsed field ablation and thermal ablation in atrial fibrillation patients.

February 21, 2026Open Access

Efficacy and safety of pulsed field ablation versus conventional thermal techniques for patients with atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

Q: What does this research mean for the field?

Pulsed field ablation shows no significant difference in treatment success or complication rates compared to conventional thermal ablation in patients with symptomatic atrial fibrillation, though it significantly reduces procedural time. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Key Result

Pulsed field ablation showed no significant difference in treatment success compared to conventional thermal ablation in patients with symptomatic atrial fibrillation (RR 1.11, 95% CI 0.87–1.42, p=0.20).

Key Points

This review aims to compare the safety and efficacy of pulsed field ablation and thermal ablation in atrial fibrillation patients.
Systematic search of multiple databases for randomized controlled trials comparing PFA with thermal ablation.
Analyzed data using risk ratios and mean differences with 95% confidence intervals.
Random-effects models applied to address heterogeneity.
No significant differences in treatment success, serious adverse events, recurrent arrhythmias, or repeat ablation between PFA and thermal techniques.
Pulsed field ablation significantly reduced procedural time by an average of 38.80 minutes.
Findings indicate comparable effectiveness and safety between PFA and conventional methods.

Study Design

Type

Meta-Analysis (n=1,294)

Structured PICO

Does pulsed field ablation improve treatment success and reduce adverse events compared to conventional thermal ablation in patients with symptomatic atrial fibrillation?

Population

1,294 adults ≥18 years of age with symptomatic atrial fibrillation (paroxysmal or persistent) eligible for pulmonary vein isolation from 4 RCTs. Mean age 64.5, 62.4% hypertension, mean CHA2DS2-VASc score 2.0. Excluded: previous left atrial ablation/surgery, valvular cardiac procedures, uncontrolled heart failure or NYHA Class III/IV.

Intervention

Pulsed field ablation (PFA) (n=653)

Comparator

Conventional thermal ablation (radiofrequency ablation or cryoballoon ablation) (n=641)

Outcome

Treatment success rate (freedom from recurrent atrial fibrillation beyond a 90-day blanking period) and adverse events (cardiac tamponade, transient ischemic attack, stroke, pulmonary vein stenosis, phrenic nerve paralysis, and atrioesophageal fistula)composite

Pulsed field ablation offers comparable efficacy and safety to conventional thermal ablation for atrial fibrillation, with the added benefit of significantly shorter procedural times.

Main Result

Effect estimate: RR 1.11 (95% CI 0.87 – 1.42)

p-value: p=0.20

Limitations

Certainty of evidence for most clinical outcomes was low to very low due to imprecision, inconsistency, and risk of bias.
High heterogeneity in procedural time outcome with sensitivity to individual studies.
Limited number of RCTs (only 4 included) and variation in follow-up durations (mostly 1 year, one with 24 hours).
Inclusion of one study combining PFA with RFA may affect homogeneity.
No detailed female percentage provided.
Limited data on long-term outcomes beyond 1 year.

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of stroke. Pulsed field ablation (PFA) emerges as a novel, non-thermal energy source offering myocardial-selective ablation with a potentially improved safety and efficacy profile. To compare the safety and efficacy of PFA versus RFA/CBA ablation in patients with AF. Multiple databases were systematically searched from inception to May 2025. Randomized Controlled Trials (RCTs) comparing PFA versus thermal ablation (TA) were analyzed using risk ratio (RR) and mean difference (MD) with 95% Confidence Intervals (CI). Random-effects model was employed to account for heterogeneity, as measured by I2 and quantified using leave-one-out analysis. We included 1,294 patients, of whom 653 (50.4%) underwent PFA from four RCTs. Among the included patients, 62.4% have hypertension and a CHA2DS2-VASc mean score of 2.0 ± 1.4. In the pooled analysis, no significant differences were found between PFA group when compared to TA regarding treatment success (RR = 1.11; 95% CI 0.87–1.42; ρ = 0.20), serious adverse events (RR = 1.24; 95% CI 0.38–4.09; ρ = 0.51), recurrent atrial arrhythmias (RR = 0.86; 95% CI 0.54–1.38; ρ = 0.31), and repeat ablation (RR = 0.89; 95% CI 0.18–4.38; ρ = 0.78). However, the procedural time (MD = -38.80 min; 95% CI -75.52–2.08; ρ = 0.04) was significantly reduced in patients who underwent PFA. PFA appears comparable to radiofrequency and cryoballoon ablation for atrial fibrillation, with shorter procedure times but similar efficacy and complication rates. Given that most outcomes were graded as low or very low certainty, further large, long-term randomized trials are needed to confirm these findings.

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