Pulsed-Field Ablation for Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis

Abstract

Background and aims: Pulsed field ablation (PFA) has emerged as a non-thermal alternative for pulmonary vein isolation (PVI), offering shorter procedural times and a favorable safety profile for atrial fibrillation (AF) ablation. However, large-scale data evaluating its efficacy in patients with persistent AF remain limited. Our objective was to perform a systematic review and meta-analysis evaluating 12-month atrial arrhythmia recurrence following PFA in patients with persistent AF.

Methods: A systematic search of MEDLINE, Embase, Scopus, LILACS, and Cochrane databases was performed. Studies including patients with persistent AF undergoing first-time PVI with PFA and reporting 12-month arrhythmia-free survival were included. When available, outcomes were compared with thermal ablation using time-to-event analyses. Random-effects models were used. Exploratory meta-regression analyses were conducted to assess potential sources of heterogeneity.

Results: Among 1699 screened studies, 26 met the inclusion criteria, comprising 3744 patients with persistent AF treated with PFA. The pooled 12-month freedom from atrial arrhythmia recurrence was 72.3% (95% CI, 69.0-75.5), with substantial heterogeneity (I² = 74.4%). Eight studies (31%) included a thermal comparator; pooled time-to-event analysis demonstrated no significant difference between PFA and thermal ablation (HR, 0.91 [95% CI, 0.78-1.07]). Exploratory meta-regression did not identify significant effect modification by baseline characteristics, lesion-set strategy, rhythm monitoring intensity, or year of publication. Ablation-related adverse events occurred in < 1% of cases for both energy sources.

Conclusion: In patients with persistent AF, PFA is associated with a high arrhythmia-free survival at 12 months and low rates of ablation-related adverse events. Comparative findings versus thermal ablation should be considered exploratory and interpreted cautiously, given the limited and heterogeneous comparator data.

Keywords: cryoballoon ablation; meta‐analysis; persistent atrial fibrillation; pulmonary vein isolation; pulsed‐field ablation; radiofrequency ablation; systematic review.