Pulsed Field Ablation Versus Thermal Ablation for First‐Time Pulmonary Vein Isolation in Atrial Fibrillation: A Systematic Review and Meta‐Analysis

Abstract

ABSTRACT Background With over 60 million cases worldwide, atrial fibrillation (AF) is one of the most common cardiac arrhythmias in adults. Pulsed‐field ablation (PFA) has emerged as a significant alternative to thermal ablation for pulmonary vein isolation (PVI). This systematic review and meta‐analysis investigated the efficacy and safety of PFA versus thermal ablation in patients undergoing first‐time PVI. Methods We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library from inception to 2025. Hazard ratios (HRs) with 95% confidence intervals (CIs) were derived from reconstructed Kaplan–Meier survival curves to compare atrial tachyarrhythmia recurrence between PFA and thermal ablation. Random‐effects models were used to compare AF recurrence, durable PVI, redo procedures, phrenic nerve palsy (PNP), and other safety outcomes between the two groups. Results A total of 27 studies comprising 8546 patients were included. Kaplan–Meier reconstruction from ten studies demonstrated higher 12‐month arrhythmia‐free survival with PFA compared with thermal ablation (78.4% [95% CI, 76.1–80.8] vs. 73.4% [95% CI, 71.5–75.4]). Thermal ablation was associated with a significantly higher risk of atrial tachyarrhythmia recurrence (HR 1.28, 95% CI 1.10–1.48; p = 0.001). Subgroup analyses demonstrated that PFA significantly reduced the recurrence risk in patients with paroxysmal AF (HR 1.63, 95% CI 1.31–2.03; p < 0.001), whereas no significant difference was observed in those with persistent AF (HR 1.13, 95% CI 0.92–1.41; p = 0.25). Conclusions PFA was associated with lower rates of atrial tachyarrhythmia and AF recurrence rates than thermal ablation in patients undergoing first‐time PVI; however, these findings should be interpreted cautiously, given the predominance of observational studies.