Pulsed-field ablation significantly shortens procedural and left atrial dwell times compared to cryoballoon and radiofrequency pulmonary vein isolation ablation 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 a more efficient ablation modality. 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. Procedural times in minutes were compared. Where reported left atrial dwell times in minutes were also compared. Results Procedure times were significantly shorter for PFA than CBA (MD: -6.54; 95% CI: -12.95 – -0.13, P = 0.05) (Figure 2.1.1). Procedure times were significantly reduced for PFA in comparison to RFA all comers (MD: -47.88 95% CI: -63.22 – -32.54, P <0.00001) (Figure 2.1.2). For subgroup analysis, procedures times were significantly shorter for PFA when compared to HPSD (MD: -36.15; 95% CI: -56.23 – -16.06, P =0.0004) (Figure 2.1.3). Moreover, procedural times were even more significantly reduced for PFA versus non-HPSD RFA (MD: -54.90; 95% CI: -78.00 – -31.80, P <0.00001) (Figure 2.1.4). Furthermore, the left atrial dwelling time was significantly quicker for PFA compared to RFA (All) (RR: -39.59; %95 CI: -55.31 – -23.87, P < 0.00001) (Figure 4.1.2). Conversely, the left atrial dwelling time was not significantly shorter for PFA compared to CBA (RR: - 9.24; %95 CI: -18.91 – 0.42, P = 0.06) (Figure 4.1.1). Conclusions (1) PFA PVI is associated with significantly shorter procedural times and reduced left atrial dwell times compared to RFA (including HPSD). (2) PFA PVI is associated with significantly reduced procedural times compared to CBA but not LA dwell time.Forrest Plot comparing procedure times Forrest Plot with left atrial dwell time