Pulsed-Field Ablation for Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis

Pulsed field ablation (PFA) has emerged as a non-thermal alternative for pulmonary vein isolation (PVI), offering shorter procedural times and a favorable safety profile for atrial fibrillation (AF) ablation. However, large-scale data evaluating its efficacy in patients with persistent AF remain limited. Our objective was to perform a systematic review and meta-analysis evaluating 12-month atrial arrhythmia recurrence following PFA in patients with persistent AF.

A systematic search of MEDLINE, Embase, Scopus, LILACS, and Cochrane databases was performed. Studies including patients with persistent AF undergoing first-time PVI with PFA and reporting 12-month arrhythmia-free survival were included. When available, outcomes were compared with thermal ablation using time-to-event analyses. Random-effects models were used. Exploratory meta-regression analyses were conducted to assess potential sources of heterogeneity.

Among 1699 screened studies, 26 met the inclusion criteria, comprising 3744 patients with persistent AF treated with PFA. The pooled 12-month freedom from atrial arrhythmia recurrence was 72.3% (95% CI, 69.0-75.5), with substantial heterogeneity (I² = 74.4%). Eight studies (31%) included a thermal comparator; pooled time-to-event analysis demonstrated no significant difference between PFA and thermal ablation (HR, 0.91 [95% CI, 0.78-1.07]). Exploratory meta-regression did not identify significant effect modification by baseline characteristics, lesion-set strategy, rhythm monitoring intensity, or year of publication. Ablation-related adverse events occurred in < 1% of cases for both energy sources.

In patients with persistent AF, PFA is associated with a high arrhythmia-free survival at 12 months and low rates of ablation-related adverse events. Comparative findings versus thermal ablation should be considered exploratory and interpreted cautiously, given the limited and heterogeneous comparator data.