Pulsed-field ablation versus thermal ablation for atrial fibrillation: a meta-analysis.

BackgroundPulsed-field ablation (PFA) is an alternative to thermal ablation (TA) in patients with atrial fibrillation (AF) receiving catheter-based therapy for pulmonary vein isolation (PVI). However, its efficacy and safety have yet to be fully elucidated.ObjectiveThis study compared PFA and TA's acute and long-term efficacies and safety.MethodsWe performed a systematic review and meta-analysis of randomized and non-randomized controlled trials comparing PFA and TA in patients with AF undergoing their first PVI ablation. The TA group was divided into cryoballoon (CB) and radiofrequency (RF) subgroups, and AF patients were divided into paroxysmal AF (PAF) and persistent AF (PersAF) subgroups for further analysis.ResultsEighteen studies involving 4,998 patients (35,2% PFA) were included. Overall, PFA was associated with a shorter procedure time (MD, -21.68; 95% CI: -32.81–[-10.54]) but longer fluoroscopy time (MD, 4.53; 95% CI: 2.18–6.88) than TA. Regarding safety, lower (peri-)esophageal injury rates (OR 0.17; 95% CI: 0.06–0.46) and higher tamponade rates (OR 2.98; 95% CI: 1.27-7.00) were observed following PFA. In efficacy assessment, PFA was associated with a better first-pass isolation rate (OR 6.82; 95% CI: 1.37-34.01) and a lower treatment failure rate (OR 0.83; 95% CI: 0,70-0.98). Subgroup analysis showed no differences in PersAF and PAF; CB was related to higher (peri)esophageal injury, lower PVI acute success, and procedure time.ConclusionCompared to TA, PFA showed better results in acute and long-term efficacy but significant differences in safety, with lower (peri)esophageal injury rates but higher tamponade rates and procedural data.