Pulsed Field Ablation for Paroxysmal Atrial Fibrillation: Early Outcomes vs Thermal Catheter Ablation

Abstract

Introduction: Pulsed field ablation (PFA) is a non-thermal ablation modality that selectively targets cardiomyocytes, potentially reducing collateral damage to esophagus and phrenic nerve. This review compares PFA to radiofrequency (RF) or cryoballoon (CB) ablation for paroxysmal atrial fibrillation (PAF).
Methods: Systematic review of single-arm and comparative studies (≥50 PAF patients, follow-up ≥6 months) reporting freedom from atrial arrhythmia (FFAA) and major adverse events (MAE: cardiac tamponade, stroke, atrioesophageal fistula, phrenic palsy). Searched: Embase, Scopus (2020–2024).
Results: Twenty studies (n=3,826 PFA, n=2,104 RF/CB) included. Single-arm FFAA off antiarrhythmic drugs at 12 months: PFA 78% (95% CI 73–83%). Comparative studies: PFA similar to RF/CB (RR for recurrence 0.96, 0.87–1.06). MAE: PFA 1.2% vs RF/CB 3.4% (p=0.002), driven by fewer cardiac tamponade (0.3% vs 1.2%) and no atrioesophageal fistula or phrenic injury in PFA arm. Procedure time shorter for PFA by 32 minutes.
Discussion: PFA achieves non-inferior efficacy with a superior safety profile, likely due to tissue-specific thresholds. However, most PFA studies had short follow-up (maximum 18 months) and were non-randomized. Long-term durability of PFA lesions unknown.
Conclusions: PFA appears safe and effective for PAF, with fewer complications than thermal ablation. Randomized controlled trials with 24-month follow-up are ongoing.