Pulsed field ablation vs. thermal ablation for pulmonary vein isolation: a network meta-analysis of randomized controlled trials

Latini AC, Penna M, Saglietto A, Landra F, Chiarito M, Villaschi A, Filiberti G, Carli S et al.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2026

4,162 participants

Abstract

Aims: Pulsed field ablation (PFA) has recently emerged as a promising alternative to conventional energy sources (ES) for atrial fibrillation (AF) ablation. However, comparative data between PFA and other ES-such as radiofrequency (RFA), cryoballoon (CBA), and laser balloon ablation (LBA)-remain limited.This network meta-analysis (CRD420251054760) aimed to compare outcomes of PFA vs. thermal ES for AF ablation.

Methods and results: A systematic network meta-analysis using PubMed, Cochrane, and EMBASE from inception to March 2026 was performed. Randomized controlled trials comparing different ES in first-attempt pulmonary vein isolation were included. Data extraction was performed according to PRISMA guidelines. The primary outcome was the recurrence of any sustained atrial tachyarrhythmia (ATA) at 12-month follow-up. Safety and efficiency outcomes were also compared among groups. We included 18 studies, encompassing 4162 patients. Compared to PFA, thermal ablation technologies showed a higher risk of ATA recurrence at 12-month follow-up (RFA: RR of 1.48 (95% CI 1.10-2.00); CBA: 1.43 (95% CI 1.07-1.92); LBA: RR 1.29 (CI 95% 0.84-1.98)). PFA exhibited the lowest procedural time among transcatheter ES, whereas RFA displayed a significantly lower fluoroscopy time. No significant differences were recorded for major periprocedural complications. A subgroup analysis restricted to studies involving only paroxysmal AF patients, as well as those employing contemporary technologies,…

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