Abstract 4365237: Pulsed-Field Ablation Achieves Superior 12-Month Arrhythmia-Free Survival, Comparable Safety, and Shorter Procedure Times Versus Thermal Ablation in Paroxysmal Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis

Introduction: Catheter ablation is a cornerstone therapy for symptomatic paroxysmal atrial fibrillation (AF), yet durable arrhythmia suppression with radiofrequency or cryo-balloon thermal energy remains sub-optimal and carries a small risk of collateral injury. Pulsed-field ablation (PFA) delivers non-thermal, tissue-selective electroporation that promises faster, safer lesions, but its performance relative to established thermal techniques has not been studied across randomized trials. We performed a focused prospective study based meta-analysis comparing PFA with thermal ablation in drug-refractory paroxysmal AF. Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified Randomized Controlled Trials (RCTs) and prospective Observational Studies (OBS) comparing Pulsed-field ablation and thermal ablation for paroxysmal AF. Data were analysed using RevMan 4.2.1. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I 2 ). Statistical significance was set at p < 0.05. Risk of bias was assessed using RoB 2.0. Results: Five RCTs encompassing 1,099 patients (PFA = 486; thermal = 613) met the eligibility criteria. PFA increased the proportion of patients free from arrhythmia, anti-arrhythmic drug re-initiation, cardioversion, or repeat ablation at 12 months by 17% versus radiofrequency/cryo-balloon approaches (RR 1.17, 95% CI 1.03–1.34; I 2 = 45%). Device- or procedure-related serious adverse events through 12 months were infrequent and statistically comparable (10/468 vs 8/590; RR 1.43, 95% CI 0.42–4.84; I 2 = 28%), and acute composite major adverse events within 7 days also showed no difference (11/486 vs 10/613; RR 1.26, 95% CI 0.39–4.07; I 2 = 28%). Sensitivity analysis revealed a non-significant trend toward lower late AF/AFL/AT recurrence with PFA (RR 0.74, 95% CI 0.51–1.08; I 2 = 51%). Mean procedure time favored PFA by 24 minutes (MD −24 min, 95% CI −42 to −6). Conclusion: Across contemporary RCTs, pulsed-field ablation delivers superior 12-month efficacy, comparable safety, and shorter procedures compared with thermal ablation for paroxysmal AF. This data supports rapid clinical adoption of PFA and justify pragmatic trials to confirm longer-term stroke prevention, quality-of-life, and healthcare-utilization benefits, potentially reshaping future AHA/ACC guideline recommendations for first-line AF ablation.