Pulsed field ablation versus cryoballoon ablation for pulmonary vein isolation in atrial fibrillation: a systematic review and meta-analysis with subgroup analyses by AF type

Pulsed field ablation (PFA) is a non-thermal alternative to cryoballoon ablation (CBA) for pulmonary vein isolation in atrial fibrillation (AF). We compared their procedural efficiency, safety, and 1-year outcomes. We searched PubMed, Scopus, Web of Science, CENTRAL, and Embase through October 2025 for randomized and comparative cohort studies of adults undergoing PFA or CBA. Outcomes were procedure duration, fluoroscopy time, left-atrial dwell time, periprocedural complications, and 1-year atrial arrhythmia recurrence, synthesized using random-effects meta-analyses with AF-type subgroup analyses. Twenty-three studies were included overall, of which 22 contributed to the quantitative synthesis. Overall, PFA shortened procedure duration versus CBA (mean difference [MD] − 11.50 min, 95% confidence interval [CI] − 15.39 to − 7.62), driven by persistent and mixed AF subgroups, while no significant difference was observed in paroxysmal AF. LA dwell time was reduced with PFA in paroxysmal AF, whereas fluoroscopy time did not differ significantly overall. Stroke, bleeding, and cardiac tamponade were comparable. PFA markedly decreased persistent (risk ratio [RR] 0.31, 95% CI 0.10–0.91) and transient (RR 0.19, 95% CI 0.07–0.53) phrenic nerve palsy. At 1 year, overall pooled analyses showed lower total atrial arrhythmia recurrence (RR 0.79, 95% CI 0.66–0.94) and AF recurrence (RR 0.72, 95% CI 0.62–0.83), with no difference in atrial flutter recurrence. PFA appears to offer shorter procedures and a more favorable phrenic-nerve safety profile than cryoballoon ablation, without evidence of excess major complications. Apparent 1-year efficacy advantages should be interpreted cautiously because the evidence base is dominated by observational studies and direct randomized PFA-versus-cryoballoon evidence remains limited.