Pulsed Field Ablation versus Thermal Energy Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis

Chaitanya Malladi, MD – Cardiology Fellow, University of California, San Diego; Frederick Han, MD – Electrophysiologist, University of California, San Diego; Kurt Hoffmayer, MD, PharmD – Electrophysiologist, University of California, San Diego; David Krummen, MD – Electrophysiologist, University of California, San Diego; Gordon Ho, MD – Electrophysiologist, University of California, San Diego; Farshad Raissi, MD – Electrophysiologist, University of California, San Diego; Ulrika Birgersdotter-Green, MD – Electrophysiologist, University of California, San Diego; Gregory Feld, MD – Electrophysiologist, University of California, San Diego; Jonathan Hsu, MD, MAS – Electrophysiologist, University of California, San Diego

Purpose: Pulsed field ablation (PFA) induces cell death through electroporation using ultrarapid electrical pulses. We sought to compare the procedural efficiency characteristics, safety and efficacy of ablation of atrial fibrillation (AF) using PFA compared with thermal energy ablation.

Material and Methods: We performed an extensive literature search and systematic review of studies that compared ablation of AF with PFA versus thermal energy sources. Risk ratio (RR) 95% confidence intervals (CI) were measured for dichotomous variables and mean difference (MD) 95% CI were measured for continuous variables, where RR < 1 and MD < 0 favors the PFA group.

Results: We included 6 comparative studies for a total of 1,012 patients who underwent ablation of AF; 43.6% with PFA (n=441) and 56.4% (n=571) with thermal energy sources. There were significantly shorter procedures times with PFA despite a protocolized 20-minute dwell time (MD -21.95, 95% CI -33.77, -10.14, p=0.0003), but with significantly longer fluroscopy time (MD 5.71, 95% CI 1.13, 10.30, p=0.01). There were no statistically significant differences in periprocedural complications (RR 1.20, 95% CI 0.59-2.44) or recurrence of atrial tachyarrhythmias (RR 0.64, 95% CI 0.31, 1.34) between the PFA and thermal ablation cohorts.

Conclusions: Based on the results of this meta-analysis, PFA was associated with shorter procedural times and longer fluoroscopy times, but no difference in periprocedural complications or rates of recurrent AF when compared to ablation with thermal energy sources. However, larger randomized control trials are needed.