Pulse field ablation versus thermal ablation: A systematic review and meta analysis of randomized controlled trials

Radiofrequency (RFA) and cryoballoon (CBA) catheter ablation are the primary thermal ablation techniques used for catheter-based ablation of atrial fibrillation (AF). Recently, pulsed field ablation (PFA), which is a nonthermal ablation technique, has been studied; however, it is unclear if PFA can improve atrial arrhythmia freedom compared to thermal ablation. A meta-analysis of randomized controlled trials comparing PFA to thermal ablation techniques (RFA and/or CBA) was conducted. The primary outcome was atrial arrhythmia freedom. The secondary outcome was a composite of serious adverse events as defined by each trial. Cumulative odds ratios (OR) and 95% confidence intervals (CI) were calculated for each treatment type. Three trials were identified that included 1,237 participants (PFA = 622, Thermal = 615). The mean age (± standard deviation) was 64.3 (±9.0) years, and 32.6% of all patients were female. All trials had a follow-up time of 12 months. PFA was not significantly associated with an increase in atrial arrhythmia freedom (OR 1.19; 95% CI 0.85 to 1.65; p = 0.31; I2=31.1) or serious adverse events (OR 1.25; 95% CI 0.48 to 3.26; p=0.64; I2=0.00). There was no evidence of effect modification on either endpoint when subgrouping by arrhythmia detection methods (continuous monitoring vs. Holter monitoring) or atrial fibrillation type (paroxysmal vs. persistent). For patients undergoing catheter ablation for AF, there is no significant improvement in atrial arrhythmia freedom with PFA compared to thermal ablation techniques. Additionally, the incidence of adverse events was similar across the two groups.