Pulsed-field ablation versus thermal ablation for atrial fibrillation: A meta-analysis

Abstract

Background: Pulsed-field ablation (PFA) is an alternative to thermal ablation (TA) in patients with atrial fibrillation (AF) receiving catheter-based therapy for pulmonary vein isolation (PVI). However, its efficacy and safety have yet to be fully elucidated.

Objective: The purpose of this study was to compare the acute and long-term efficacies and safety of PFA and TA.

Methods: We performed a systematic review and meta-analysis of randomized and nonrandomized controlled trials comparing PFA and TA in patients with AF undergoing their first PVI ablation. The TA group was divided into cryoballoon (CB) and radiofrequency subgroups. AF patients were divided into paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PersAF) subgroups for further analysis.

Results: Eighteen studies involving 4998 patients (35.2% PFA) were included. Overall, PFA was associated with a shorter procedure time (mean difference [MD] -21.68; 95% confidence interval [CI] -32.81 to -10.54) but longer fluoroscopy time (MD 4.53; 95% CI 2.18-6.88) than TA. Regarding safety, lower (peri-)esophageal injury rates (odds ratio [OR] 0.17; 95% CI 0.06-0.46) and higher tamponade rates (OR 2.98; 95% CI 1.27-7.00) were observed after PFA. In efficacy assessment, PFA was associated with a better first-pass isolation rate (OR 6.82; 95% CI 1.37-34.01) and a lower treatment failure rate (OR 0.83; 95% CI 0.70-0.98). Subgroup analysis showed no differences in PersAF and PAF. CB was related to higher (peri)esophageal injury, and lower PVI acute success and procedural time.

Conclusion: Compared to TA, PFA showed better results with regard to acute and long-term efficacy but significant differences in safety, with lower (peri)esophageal injury rates but higher tamponade rates in procedural data.

Keywords: Cryoballoon ablation; Paroxysmal atrial fibrillation; Persistent atrial fibrillation; Pulmonary vein isolation; Pulsed-field ablation; Radiofrequency ablation; Thermal ablation.

Graphical abstract

Figure 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of search results and reasons for exclusion of studies.

Figure 2

Mean difference (MD) and funnel plots for procedural data. A: Procedural time (minutes). B: Fluoroscopy time (minutes). C: Procedural time subgroup analysis (minutes): pulsed-field ablation (PFA) vs cryoballoon (CB) or radiofrequency (RF) D: Fluoroscopy time subgroup analysis (minutes): PFA vs CB or RF. Size of data markers in the forest plot indicate the weight of the study in the pooled analysis. Markers in the funnel plot indicate the distribution of studies around the estimated effect size. CI = confidence interval; IV = inverse variation.

Figure 3

Odds ratios (ORs) and funnel plots for acute and long-term procedural efficacy. A: Acute Success pulmonary vein isolation. B: First-pass Isolation. C: Treatment failure was defined as <1 year and >1 year of follow-up. D: Treatment failure in PFA vs CB or RF patients. Size of data markers indicate the weight of the study in the pooled analysis. Markers in the funnel plot indicate the distribution of the studies around the estimated effect size. MH = Mantel-Haenszel; other abbreviations as in Figure 2.

Figure 4

Odds ratio and funnel plot long-term procedure efficacy, subgroup analysis with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PersAF) patients. A: Treatment failure in patients with PAF and PersAF. B: Treatment failure in patients with PAF compared to CB vs RF ablation. C: Treatment failure in patients with PersAF compared with CB vs RF ablations D: Treatment failure in patients with PersAF compared to CB vs RF ablation. Size of data markers indicates weight of study in the pooled analysis. Markers in funnel plot indicate the distribution of the studies around the estimated effect size. Abbreviations as in Figures 2 and 3.

Figure 5

Odds ratios and funnel plots for procedural adverse events. A: Overall periprocedural complications. B: Subanalysis of periprocedural complications in PFA vs CB or RF. C: (Peri-)esophageal injuries. D: Tamponades. E: High-sensitivity troponin levels. Size of data markers indicate the study's weight in the pooled analysis. Markers in the funnel plot indicate the distribution of the studies around the estimated effect size. Abbreviations as in Figures 3 and 4.