Outcomes of Pulsed Field Versus Cryoballoon Ablation in Atrial Fibrillation: A Comprehensive Systematic Review and...

Catheter-based pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). While cryoballoon ablation (CBA) is a well-validated single-shot thermal technology, pulsed field ablation (PFA) has emerged as a predominantly non-thermal modality that employs high-voltage electric fields to achieve selective myocardial ablation, potentially minimizing collateral damage. However, comparative evidence between PFA and CBA remains limited.

To systematically review and compare the efficacy, safety, and procedural efficiency of PFA versus CBA for PVI.

A structured systematic database search was conducted up to August 2025, following PRISMA guidelines. Eighteen studies (n = 5638; 2396 PFA and 3242 CBA) were included including two randomized controlled trials. PFA significantly shortened procedure time (mean difference -13.7 min; 95% CI -16.7 to -10.8; p < 0.001), while fluoroscopy time and radiation dose were similar. Both modalities achieved high acute PVI success (95%-100%). At 12-month follow-up, PFA showed lower arrhythmia recurrence (OR 0.73; 95% CI 0.59-0.90; p = 0.003) with no difference in redo ablation. Overall complications were fewer with PFA (OR 0.53; 95% CI 0.32-0.87; p < 0.001), largely due to reduced phrenic nerve injury, though cardiac tamponade occurred slightly more often in the PFA group. Subgroup analyzes yielded consistent results in paroxysmal AF and when 3D mapping was used.

PFA offers superior procedural efficiency and safety compared with CBA, achieving shorter procedures, fewer complications, and lower arrhythmia recurrence at mid-term follow-up. Larger multicentre randomized trials with standardized protocols and long-term follow-up are needed to confirm these findings and evaluate evolving PFA technologies.