Pulsed Field Ablation for Atrial Fibrillation in the Elderly ≥75 Years Old: A Systematic Review and Meta-Analysis

Pulse field ablation (PFA) is an emerging catheter ablation strategy for patients with atrial fibrillation (AF). Nonetheless, the safety and efficacy of PFA in elderly patients remains scarce. Hence, this study is to provide a comprehensive review of PFA utilization in the elderly.

A systematic search was conducted from the inception of PubMed to July 2025 comparing the safety and efficacy of PFA in elderly (≥75 years) and non-elderly patients. Safety outcomes were the rate of overall procedure-related complications, major complications (stroke/TIA, cardiac tamponade, phrenic nerve injury, valve damage, myocardial infarction), and minor complications. Efficacy outcomes include time to arrhythmia recurrence and rate of arrhythmia-free survival.

Ten studies with a total of 5948 patients (900 elderly and 5048 non-elderly) were included in the analysis. In the elderly group, the rate of overall and major complications was 3% (95% CI 2%-6%, I² = 0%) and 1% (95% CI 1%-2%, I² = 0), respectively. However, elderly patients still had a higher risk of overall complications (OR 1.93, 95% CI 1.29-2.91, I² = 0%, p = 0.020), major complications (OR 1.93, 95% CI 1.11-3.35, I² = 0%, p = 0.033), and minor complications (OR 2.08, 95% CI 1.19-3.64, I² = 0%, p = 0.030), compared to non-elderly patients. The rate of arrhythmia-free survival was similar in each group (OR 0.81, 95% CI 0.41-1.59, I² = 0%, p = 0.315). No significant differences were observed in procedural time (MD -2.54 min, 95% CI -14.76 to 9.68, I² = 88.6%, p = 0.595) and fluoroscopy time (MD -0.8 min, 95% CI -3.11 to 1.51, I² = 80%, p = 0.392).

Our study demonstrated that, in the elderly, there was a similar efficacy in PFA for AF, but with a higher tendency for complications, compared to non-elderly patients.