Pulsed-field ablation significantly reduces arrhythmia recurrence 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 assess the efficacy of PFA versus CBA and RFA (including HPSD) in performing PVI for AF and determine whether PFA is associated with lower arrhythmia recurrence rates following PVI ablation for AF. Methods A systematic review with a meta-analysis of 12 published 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. A recurrence was defined as an arrhythmia lasting more than 30 seconds on clinical follow-up of more than 3 months-post ablation. Results Mean follow-up was 10.74 months. The recurrence rates were significantly lower for PFA compared to all comers in RFA (RR: 0.77; 95% CI: 0.67 – 0.88, P = 0.0001) (Figure 1.1.2). For a subgroup analysis, PFA recurrence rates were trending lower than the HPSD-RFA group (RR:0.79; 95% CI: 0.61 – 1.03, P = 0.08) (Figure 1.1.3). Notably, PFA compared favourably with significantly lower recurrence rates than non-HPSD RFA (RR: 0.75 95% CI: 0.64 – 0.88, P = 0.0003) (Figure 1.1.4). Finally, PFA was superior to CBA as it was associated with significantly lower recurrence rates (RR: 0.84; 95% CI: 0.71 – 1:00, P = 0.05) (Figure 1.1.1). Conclusions (1) PVI using PFA was efficacious and associated with lower arrhythmia recurrences than non-HPSD RFA. (2) PVI using PFA trended towards a lower recurrence rate than HPSD RFA. (3) PVI using PFA was associated with significantly lower arrhythmia recurrence rates than CBA.Forrest Plot comparing treatment failure