Pulsed-field ablation versus conventional thermal ablation for atrial fibrillation: a meta-analysis of randomised controlled trials

Pulsed-field ablation is a novel ablation technique using non-thermal energy. Although several studies have reported the efficacy and safety of pulsed-field ablation for atrial fibrillation, results from randomised controlled trials (RCTs) are limited.

The aim of this study was to compare pulsed-field ablation with conventional thermal ablation in patients with atrial fibrillation.

We conducted a meta-analysis of RCTs. PubMed, the Cochrane Central Register of Controlled Trials, the web of science, and ClinicalTrials.gov were searched through February 2025 for the terms "radiofrequency OR cryoballoon OR hotballoon OR laser balloon," "pulsed field," "ablation," and "atrial fibrillation." The same terms or related studies were also searched in relevant reviews. The clinical endpoint of this study was recurrence of atrial arrhythmia, complications, total procedure time, and fluoroscopy time. Pooled estimates were calculated using a random-effects model. A two-sided p value < 0.05 was considered statistically significant. RevMan 5.4.1 was used for analysis.

A total of 906 patients in 4 RCTs were included in this study. Pulsed-field ablation significantly reduced total procedure time compared with conventional thermal ablation (mean difference (MD) -55.04 min.; 95% confidence interval (CI) [-92.74, -17.35]; p = 0.004). On the other hand, fluoroscopy time (MD 3.51 min.; 95% CI [-2.07, 9.08]; p = 0.22) recurrence of atrial arrhythmia (odds ratio (OR) 0.51; 95% CI [0.17, 1.51]; p = 0.23), and occurrence of complications (OR 0.80; 95% CI [0.32, 2.05]; p = 0.65) were similar between the 2 groups.

In patients with atrial fibrillation, pulsed-field ablation may be associated with reduction in total procedure time, but not fluoroscopy time, recurrent atrial arrhythmia, or complications as compared with conventional thermal ablation. Further large-scale RCTs are warranted to validate the efficacy and safety of pulsed-field ablation.