Pulsed-field ablation versus thermal ablation for atrial fibrillation: an updated systematic review and meta -analysis of randomized controlled trials and observational studies with time-to-event analysis

Humayun Z.; Majeed M.W.; Joshi D.K.; Ayesha A.; Ruelas M.G.; Consoli L.; Baqal O.; Arham M.; Wani S.A.; Azeem B.; Naveed M.A.; Ali A.; Silva B.R.; Kofahi A.; Munir M.B.; DeSimone C.V.; Lee J.Z.; Asif T. · Journal of Interventional Cardiac Electrophysiology (2026) · DOI: 10.1007/s10840-026-02282-1

Resumen

Introduction: Pulsed-field ablation (PFA) has demonstrated promising efficacy and safety for atrial fibrillation ablation. However, significant gaps remain regarding its overall performance and long-term outcomes when compared to thermal ablation. Methods: We systematically searched Pubmed, Embase and Cochrane Central for studies comparing PFA and thermal ablation for pulmonary vein isolation in patients with paroxysmal or persistent atrial fibrillation reporting at least one outcome of interest. We used risk ratio (RR) with 95% confidence intervals (CIs) as the effect size measure for binary outcomes, Mean Differences (MD) with 95% confidence intervals were used for continuous outcomes, employing a random-effects model. We incorporated comprehensive sub-group and Kaplan-Meier survival analyses. Results: We included 22 studies (n = 6,056) including 3 RCTs. PFA demonstrated a lower risk of acute treatment failure compared to thermal ablation (RR: 0.85; 95%CI: 0.75–0.96), with no subgroup difference noted in the RCT subgroup (RR: 0.84; 95% CI: 0.67–1.06). PFA also achieved higher likelihood of achieving first pass isolation (RR: 1.15; 95% CI: 1.02–1.29), while significantly decreasing overall procedure duration (MD: -22.96 min; 95% CI: -30.35 to -15.58) but increasing fluoroscopy time (MD: 3.89 min; 95% CI: 5.97 to 1.81). In terms of safety, PFA significantly reduced the risk of periesophageal injuries (RR: 0.29; 95% CI: 0.12–0.69) and phrenic nerve palsy (RR: 0.27; 95% CI: 0.12–0.62), but a higher risk of cardiac tamponade (RR: 2.37; 95% CI: 1.17–4.82). No significant differences were observed in bleeding, mortality, systemic embolic events, or vascular complications. Conclusion: Our updated analysis demonstrates that PFA is a promising alternative to traditional thermal ablation techniques for atrial fibrillation, offering improved procedural efficiency and a favorable safety profile, particularly with lower periesophageal injury. © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2026.