Outcomes With Pulsed Field Ablation Versus Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation: A Meta-Analysis

Background: Pulmonary vein isolation is a standard therapy for paroxysmal atrial fibrillation (AF). Pulsed field ablation (PFA) has emerged as a novel approach aiming to improve efficacy and safety over conventional thermal ablation (CTA) (radiofrequency and cryoballoon). This meta-analysis evaluated outcomes of PFA versus thermal ablation in paroxysmal AF. Methods: Electronic databases were searched through May 2025 for randomized controlled trials (RCTs) and observational studies that compared the efficacy and safety of PFA versus CTA. The primary outcome was AF recurrence. Summary estimates were conducted using random effects. Results: A total of six studies, involving 1928 patients, were included. The incidence of AF recurrence was significantly lower among patients treated with PFA (risk ratio [RR] 0.67; 95% confidence interval [CI] 0.53–0.85). PFA was associated with a lower incidence of any atrial arrhythmia recurrence (RR 0.78, 95% CI: 0.61–0.99). The total procedure duration was significantly shorter with PFA (mean difference −21.46 min (95% CI: −26.04 to −16.88)), but there was no difference in fluoroscopy time. The rates of esophageal injury and phrenic nerve palsy were lower with PFA. However, the data were limited for these two outcomes, and a meta-analysis was not conducted for them. There was no difference between the two groups in the incidence of stroke or pericardial tamponade. Conclusion: Among patients with paroxysmal AF undergoing catheter ablation, PFA is associated with favorable outcomes, including lower recurrence and shorter procedure time compared to conventional ablation modalities.