Evaluation of pulsed-field ablation for paroxysmal atrial fibrillation: a systematic review

Atrial fibrillation (AF) is a common arrhythmia with high morbidity and mortality. Pulsed-field ablation (PFA) is an emerging non-thermal treatment for AF, offering potential advantages over conventional radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in terms of safety and efficacy.

This systematic review, registered in PROSPERO and conducted in line with PRISMA-P guidelines, assessed the efficacy and safety of PFA compared to conventional ablation methods (radiofrequency and cryoballoon) for treating paroxysmal AF in adults. A comprehensive literature search (2019-2025) was performed across multiple databases, with independent screening, data extraction, and bias assessment conducted by two reviewers using validated tools (RoB 2 and ROBINS-I), culminating in a qualitative synthesis due to study heterogeneity.

PFA demonstrates promising efficacy in paroxysmal AF, with freedom from atrial arrhythmias at 12 months comparable to CBA and RFA. It also shows comparable first-pass pulmonary vein isolation (PVI) rates and shorter procedure time. Safety outcomes are favourable, with low incidence of adverse events, including no reported atrioesophageal fistulas, low rates of coronary spasm (0.14%) and haemolysis-related kidney injury (0.03%).

PFA is an effective and safe alternative to traditional ablation techniques in paroxysmal AF. Further research through large-scale registries and long-term surveillance is needed to address rare complications and fully assess its safety profile.