Autonomic profile changes after pulsed-field versus thermal ablation in patients with atrial fibrillation: a systematic review and meta-analysis
I Antoun, A Elmewafy, E Jamileh, A Abdelrazik, M Eldesouky, M T Kaung, M Ibrahim, R Somani, G A NgAbstract
Background
Catheter ablation is an established therapy for atrial fibrillation (AF). Thermal modalities, such as radiofrequency and cryoballoon ablation, achieve pulmonary vein isolation but induce collateral autonomic denervation, which manifests as an increased resting heart rate (HR) and reduced heart rate variability (HRV). Pulsed-field ablation (PFA) is a non-thermal alternative that selectively targets cardiomyocytes while potentially sparing autonomic structures. Its autonomic impact, relative to thermal ablation, remains incompletely understood.
Purpose
This systematic review and meta-analysis aimed to compare autonomic changes following PFA and thermal ablation in AF, focusing on resting HR, bradyarrhythmias, and arrhythmia recurrence.
Methods
Electronic databases were searched through August 2025 for randomised and non-randomised studies reporting autonomic outcomes before and after AF ablation. Eligible studies included adult patients undergoing PFA or thermal ablation. Data were synthesised using random- or fixed-effects models depending on heterogeneity.
Results
Six studies comprising 800 patients were included (PFA: 393; thermal: 407). Study details are demonstrated in Table 1. Thermal ablation produced a significantly greater increase in resting HR (mean difference 7.6 bpm, 95% CI 3.5–11.7, p=0.0003; I²=88%). In individual cohorts, increases of 6–10 bpm were consistently observed by 3–12 months after thermal ablation, whereas PFA showed minimal change. HRV indices were consistently preserved with PFA: the standard deviation of all normal-to-normal RR intervals (SDNN) at 12 months was ~150 ms with PFA, compared to ~115 ms with thermal ablation (p < 0.001). The incidence of bradyarrhythmias did not differ significantly between groups (OR 2.09, 95% CI 0.02–178.9, p=0.74; I²=94%), although transient vagal reactions occurred more often with PFA. Arrhythmia recurrence rates were comparable (OR 0.96, 95% CI 0.47–1.99, p = 0.92; I² = 0%). Acute pulmonary vein isolation success exceeded 95% across all modalities (Figure 1).
Conclusions
Thermal ablation produces greater autonomic perturbation than PFA, reflected by higher resting HR and reduced HRV. PFA preserves autonomic tone while maintaining equivalent arrhythmia outcomes, supporting its role as an effective and autonomically sparing ablation modality in AF.Baseline characteristics of studiesForrest plots of study outcomes