Pulsed field versus thermal ablation for atrial fibrillation: a systematic review and meta-analysis of efficacy, safety and procedural performance
A Campos Munoz, A Calderon Fernandez, M Torres Chavez, S Rodriguez Rodriguez, J Gasca, S Martinez Topete, F Ramos Pillado, O Camacho HernandezAbstract
Background
Catheter ablation using thermal energy is an established treatment for atrial fibrillation but may be associated with collateral injury and prolonged procedural duration. Pulsed field ablation is a non-thermal, tissue-selective modality designed to improve myocardial specificity and procedural efficiency.
Purpose
To compare the efficacy, safety and procedural performance of pulsed field ablation versus thermal ablation in atrial fibrillation.
Methods
We performed a systematic review according to PRISMA recommendations of PubMed, Embase, Scopus and Web of Science up to February 15, 2026. Randomised and observational studies comparing pulsed field with thermal ablation were included. Risk of bias was assessed using RoB 2 for RCTs and ROBINS-I for observational studies. The primary outcome was atrial arrhythmia freedom at 12 months. Secondary outcomes included serious adverse events, procedure time, fluoroscopy time, left atrial dwell time and total ablation time. Risk ratios, mean differences and standardised mean differences with 95% confidence intervals were calculated using random-effects models. Heterogeneity was assessed using the I² statistic.
Results
A total of 3,431 patients from 19 studies (3 randomised controlled trials, 16 observational cohorts) were included. Pulsed field ablation was associated with greater atrial arrhythmia freedom (risk ratio 1.09; 95% confidence interval 1.04–1.15; p=0.0006; I²=28%). Serious adverse events did not differ significantly (risk ratio 0.81; 95% confidence interval 0.51–1.28; p=0.36; I²=3%). Procedure time was shorter (mean difference −16.11 minutes; 95% confidence interval −23.34 to −8.89; p<0.0001), though with substantial heterogeneity (I²=98%). Fluoroscopy time (standardised mean difference −0.42; 95% confidence interval −0.49 to −0.35; p<0.00001; I²=97%), left atrial dwell time (standardised mean difference −0.84; 95% confidence interval −0.96 to −0.72; p<0.00001; I²=96%), and total ablation time (mean difference −24.34 minutes; 95% confidence interval −26.09 to −22.58; p<0.00001; I²=95%) were also significantly reduced. Risk of bias was low in RCTs and moderate to serious in observational studies.
Conclusion
Pulsed field ablation was associated with greater arrhythmia freedom without increased serious adverse events. Procedural durations were consistently shorter, although substantial heterogeneity in time-based outcomes highlights variability across studies. These findings support pulsed field ablation as an effective and efficient strategy, though the inclusion of observational data warrants cautious interpretation. Standardised protocols are needed in future research.Graphical AbstractFOREST PLOTS