Comparing pulsed field ablation with very high-power and high-power short-duration radiofrequency ablation for atrial fibrillation: a systematic review and meta-analysis

Background: Catheter ablation is a key treatment for atrial fibrillation (AF), with high-power, very high-power short-duration and pulsed field ablation (PFA) being efficient options. However, direct comparisons between these techniques are lacking.

Objective: We performed a systematic review and meta-analysis, which included predominantly observational studies (four retrospective and one prospective study), to compare PFA and High-power short-duration (HPSD) and very high-power short-duration (vHPSD) radiofrequency (RF) ablation in patients with AF.

Methods: We searched PubMed, Embase and Cochrane Central. Outcomes of interest included: Arrhythmia-free survival (AF, atrial flutter, and atrial tachycardia recurrences 30 s during follow-up after a 1-month blanking period), procedure time, fluoroscopy time, fluoroscopy dose, complications overall. Statistical analysis was performed using the R program (version 4.3.2). Heterogeneity was assessed with I² statistics.

Results: Our meta-analysis included 1,255 patients from 5 studies, with a mean age ranging from 63 to 68 years. Among them, 554 (45.2%) underwent pulsed field ablation (PFA) and 701 (55.8%) received high/very high potential short-duration ablation. PFA improved arrhythmia-free survival (RR 1.05; 95% CI 1.002-1.120; P = 0.004; I² = 0%) and reduced procedure time (MD -29.95 min; 95% CI -30.90 to -29.00; P < 0.01; I² = 0%). However, PFA increased fluoroscopy time (MD 6.33 min; 95% CI 1.65 to 11.01; P < 0.01; I² = 98%) and showed no significant difference in overall complications (RR 0.88; 95% CI 0.38-2.02; P = 0.756; I² = 47%), cardiac tamponade (RR 1.62; 95% CI 0.27-9.85; P = 0.599; I² = 40%), or stroke/transient ischemic attack (TIA) incidence (RR 0.64; 95% CI 0.15-2.80; P = 0.555; I² = 0%). PFA was associated with a reduced need for redo procedures (RR 0.66; 95% CI 0.45-0.97; P = 0.036; I² = 0%) and did not significantly affect the fluoroscopy dose (MD 896.86 mGy·cm²; 95% CI -1269.44 to 3063.15; P = 0.42; I² = 39%).

Conclusion: In this meta-analysis, PFA was associated with improved arrhythmia-free survival and reduced procedure time, although it resulted in increased fluoroscopy time. PFA and high/very high power short-duration ablation yielded similar outcomes regarding overall complications, cardiac tamponade, and stroke/TIA incidence. Both techniques demonstrated comparable efficacy in treating atrial fibrillation.