Contemporary pulsed field ablation systems for atrial fibrillation: a systematic review and network meta-analysis
A S T Leow, F Q Goh, J S Y Ho, Y H Teo, A C L Yip, E S J Tan, E Boey, T W Lim, K M W Leong, W T Yeo, S C Seow, W Y LimAbstract
Background
Pulsed field ablation (PFA) is an emerging non-thermal technology for atrial fibrillation (AF) ablation with promising advantages in tissue selectivity, procedural efficiency, and safety. However, comparative evidence across commercially available PFA systems remains limited.
Purpose
We aimed to systematically synthesise and compare the baseline characteristics, procedural efficiency, and safety of PFA systems (FARAPULSETM, PulseSelectTM, VARIPULSETM, VoltTM) used for pulmonary vein isolation (PVI) in AF.
Methods
A comprehensive systematic review of PubMed, Embase, Scopus, and Cochrane was conducted up to 17 October 2025. Studies of AF patients undergoing PVI with commercially available PFA systems (FARAPULSETM, PulseSelectTM, VARIPULSETM, VoltTM) that reported PFA-stratified procedural and safety outcomes were included. Random-effects meta-analyses and network meta-analyses were performed.
Results
A total of 97 studies involving 45563 patients were included, with majority being observational cohorts (69.1%, n = 67), and involved FARAPULSETM (85.6%, n = 83). Total complication rates were low across all PFA systems (0.4 – 2.0%); pooled procedural time was shortest with FARAPULSETM (68.2 mins, 95% CI 62.8 – 73.5), while fluoroscopy time was shortest with VARIPULSETM (7.7 mins, 95% CI 1.9 – 13.6). On network meta-analysis of studies with multiple PFA systems (n = 15), FARAPULSETM ranked best for procedural time and complication rates, while VARIPULSETM ranked best for fluoroscopy time.
Conclusion
All four PFA systems studied demonstrated high levels of safety and procedural efficiency for atrial fibrillation ablation. FARAPULSE™ currently possessed the most mature evidence base and reported the shortest procedural times in real-world registries, while VARIPULSE™ showed potential for significantly lower fluoroscopy exposure. Ultimately, the choice of system may depend on specific procedural goals, and the clinical landscape will continue to evolve with emerging evidence and longer-term follow-up for newer platforms.