Tailoring AF therapy: comparative efficacy of surgical, hybrid, thermal, and pulsed field ablation across patient subgroups
K Abdelsayed, M D Gabra, M B Helal, A Fathy, K Ali, A A Metwally, A A Ibrahim, A M Sror, Y Goudy, A R Allam, M A Orabi, S Gamal, M T Desouki, D R Witt, J SenguptaAbstract
Background
Atrial fibrillation (AF) can be treated using several rhythm-control strategies, yet selecting the optimal modality for an individual patient remains challenging. Patients differ in atrial substrate, comorbidities, AF chronicity, and procedural risk. As newer technologies such as pulsed field ablation (PFA) are increasingly used alongside established thermal, hybrid, and surgical approaches, understanding how these modalities perform across different patient profiles is essential for individualized therapy selection.
Objective
To compare the efficacy and safety of contemporary AF ablation strategies—surgical, hybrid, thermal, and PFA—as well as medical therapy.
Methods
We searched PubMed, Scopus, Web of Science, and Cochrane databases from inception through August 2025 for randomized controlled trials (RCTs) evaluating at least one AF ablation modality versus another or medical therapy. The primary efficacy endpoint was atrial arrhythmia recurrence; secondary endpoints included freedom from atrial tachyarrhythmia, serious adverse events (SAEs), and all-cause mortality. Subgroup analyses were performed by age (<60 vs ≥60), AF type (paroxysmal vs persistent), and AF chronicity (<3 vs ≥3 years). A frequentist random-effects network meta-analysis (NMA) was conducted in R.
Results
Thirty-six RCTs involving 5,532 patients were included. Hybrid and surgical ablation produced the greatest reductions in arrhythmia recurrence (RR 0.36, 95% CI 0.18–0.73; and RR 0.36, 95% CI 0.15–0.91) (Figure 1A). These benefits were most pronounced in older patients, in persistent AF, and in those with AF duration ≥3 years (Figure 2). Hybrid ablation also trended toward higher freedom from atrial tachyarrhythmia, though not statistically significant (Figure 1B). Both hybrid and surgical approaches showed numerically higher but nonsignificant SAE rates (RR 2.66 and RR 2.60, respectively) (Figure 1C). PFA demonstrated efficacy and safety comparable to thermal ablation. Medical therapy ranked lowest for rhythm control but had the most favorable safety profile. Mortality was similar across treatment arms (Figure 1D).
Conclusion
Hybrid and surgical ablation provide the highest efficacy—particularly in older patients and those with persistent or long-standing AF—though with a potential trade-off of increased procedural risk. PFA performs similarly to thermal ablation across major endpoints, while medical therapy remains the safest but least effective option. Future studies should focus on tailoring ablation strategy to patient-specific characteristics to optimize individualized AF management.