Safety profile of pulsed-field ablation compared to cryoballoon and radiofrequency pulmonary vein isolation ablation for atrial fibrillation in a meta-analysis of 12 studies

Abstract Background Pulsed field ablation (PFA) is a novel ablation modality for performing pulmonary vein isolation (PVI) in the treatment of atrial fibrillation (AF). The current literature has not reached a consensus on PFA’s superiority over Cryoballoon ablation (CBA) and Radiofrequency ablation (RFA) including High Power Short Duration technology (HPSD). Aim To determine the safety profile of PFA compared to CBA and RFA (including HPSD). Methods A systematic review with a meta-analysis of studies that compared PFA to CBA or RFA (including HPSD), or PFA to both, was conducted. The Medline, PubMed, and Cochrane libraries were utilised. Patients with paroxysmal and persistent AF were included. Peri-procedural complication rates were studied. Results PFA was associated with significantly lower rates of persistent Phrenic Nerve (PN) injury (RR: 0.15, 95% CI: 0.04 – 0.51, P = 0.002) (Table 2.2), and transient PN injury than CBA (RR: 0.09, 95% CI: 0.02 – 0.37, P = 0.001) (Table 2.2). PFA is associated with significantly higher rates of cardiac tamponade than CBA (RR: 3.00, 95% CI: 1.07 – 8.42, P = 0.04) (Table 2.2). There were no statistically significant differences between the PFA and RFA groups (Table 2.1). Conclusion (1) PFA PVI is associated with significantly lower rates of both persistent and transient PN injuries compared to CBA. (2) However, PFA PVI is associated with higher risks of cardiac tamponade compared to CBA but not with RFA. Further randomised controlled trials are warranted.Table 2.1: Complications for PFA vs RFA Table 2.2: Complications for PFA vs CBA