Efficacy and safety of pulsed field ablation versus radiofrequency ablation for atrial fibrillation: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

GUO Dan ¹ , ZHU Liting ¹ , CHEN Yang ² , LIU Shidong ² , LIU Hongxu ¹ ,  SONG Bing ²

1. The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, P. R. China;
2. Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, 730000, P. R. China;

Corresponding author：

SONG Bing, Email: songbinldyy@163.com

Keywords：

Pulsed field ablation; radiofrequency ablation; atrial fibrillation; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202505040

Video：

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Objective To systematically evaluate the effectiveness and safety of pulsed field ablation (PFA) and radiofrequency ablation (RFA) in the treatment of atrial fibrillation. Methods Computer searches were conducted on PubMed, EMbase, The Cochrane Library, The Web of Science, China Biomedical Literature Database, CNKI, Wanfang, and VIP databases, with a search period from the establishment of each database until April 2025. Two researchers conducted literature screening, data extraction, and quality evaluation of the included studies based on predetermined inclusion and exclusion criteria. Standardized electronic forms were used for data extraction, with a focus on the balanced dataset after propensity score matching (PSM). Quality evaluation was conducted using the improved Newcastle Ottawa scale (NOS). Meta analysis was conducted using RevMan 5.4 and Stata 18.0 software, and subgroup analysis was performed based on the study type (whether PSM method was used or not). Results Finally, 14 studies were ultimately included, of which 6 studies applied the PSM method, with a total sample size of 3 172 cases (PFA group: 1 582 cases; RFA group: 1 590 cases. NOS score≥5 points. The meta-analysis results showed that the PFA group had a lower recurrence rate of atrial fibrillation [OR=0.75, 95%CI (0.63, 0.90), P=0.002], surgical complications [OR=0.63, 95%CI (0.41, 0.98), P=0.04], and surgical time [WMD=–37.32, 95%CI (–45.85, –28.78), P<0.001] compared to the RFA group, and the differences were statistically significant. In addition, compared to the PFA group, the RFA group had a shorter X-ray exposure time [WMD=7.65, 95%CI (4.41, 10.88), P<0.001], and the difference was statistically significant. There was no statistically significant difference between the two groups in terms of re ablation rate [OR=1.17, 95%CI (0.59, 2.31), P=0.65] and acute surgical success rate [OR=0.86, 95%CI (0.22, 3.35), P=0.82]. Conclusion Compared with RFA, PFA treatment for atrial fibrillation can reduce the recurrence rate, shorten the surgical time, and reduce surgical complications, indicating its good effectiveness and safety in the treatment of atrial fibrillation.

1.	Antoun I, Layton GR, Nizam A, et al. Hypertension and atrial fibrillation: bridging the gap between mechanisms, risk, and therapy. Medicina (Kaunas), 2025, 61(2): 362.
2.	Hu D, Barajas-Martinez H, Zhang ZH, et al. Advances in basic and translational research in atrial fibrillation. Philos Trans R Soc Lond B Biol Sci, 2023, 378(1879): 20220174.
3.	Jiang X, Ling J, Xiong Q, et al. Global, regional, and national burden of atrial fibrillation/flutter related to metabolic risks over three decades: estimates from the global burden of disease study 2019. Eur Heart J Qual Care Clin Outcomes, 2024, 10(5): 391-401.
4.	Ko D, Chung MK, Evans PT, et al. Atrial fibrillation: a review. JAMA, 2025, 333(4): 329-342.
5.	Karnik AA, Saczynski JS, Chung JJ, et al. Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study. J Am Geriatr Soc, 2022, 70(10): 2818-2826.
6.	Gao L, Nguyen D, Moodie M. Economic burden of dementia caused by cardiovascular disease in Australia. J Alzheimers Dis, 2022, 86(2): 601-612.
7.	Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2024, 45(36): 3314-3414.
8.	Chan YH, Chao TF, Chen SW, et al. Clinical outcomes in elderly atrial fibrillation patients at increased bleeding risk treated with very low dose vs. regular-dose non-vitamin K antagonist oral anticoagulants: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother, 2023, 9(8): 681-691.
9.	Pannone L, Mouram S, Della Rocca DG, et al. Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience. Europace, 2023, 25(5): euad114.
10.	Kistler PM, Chieng D, Sugumar H, et al. Effect of catheter ablation using pulmonary vein isolation with vs without posterior left atrial wall isolation on atrial arrhythmia recurrence in patients with persistent atrial fibrillation: the CAPLA randomized clinical trial. JAMA, 2023, 329(2): 127-135.
11.	Winkle RA, Mead RH, Engel G, et al. Very long term outcomes of atrial fibrillation ablation. Heart Rhythm, 2023, 20(5): 680-688.
12.	Chun KJ, Miklavčič D, Vlachos K, et al. State-of-the-art pulsed field ablation for cardiac arrhythmias: ongoing evolution and future perspective. Europace, 2024, 26(6): euae134.
13.	Batista Napotnik T, Polajžer T, Miklavčič D. Cell death due to electroporation: a review. Bioelectrochemistry, 2021, 141: 107871.
14.	Schmidt B, Bordignon S, Neven K, et al. EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation: lessons from the multi-centre EU-PORIA registry. Europace, 2023, 25(7): euad185.
15.	Calvert P, Mills MT, Xydis P, et al. Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: a real-world study. Heart Rhythm, 2024, 21(9): 1537-1544.
16.	De Becker B, El Haddad M, De Smet M, et al. Procedural performance and outcome after pulsed field ablation for pulmonary vein isolation: comparison with a reference radiofrequency database. Eur Heart J Open, 2024, 4(2): oeae014.
17.	Della Rocca DG, Marcon L, Magnocavallo M, et al. Pulsed electric field, cryoballoon, and radiofrequency for paroxysmal atrial fibrillation ablation: a propensity score-matched comparison. Europace, 2023, 26(1): euae016.
18.	Dello Russo A, Compagnucci P, Anselmino M, et al. Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: results of a multicenter, real-world experience. Heart Rhythm, 2024, 21(9): 1526-1536.
19.	Gerstenfeld EP, Mansour M, Whang W, et al. Autonomic effects of pulsed field vs thermal ablation for treating atrial fibrillation: subanalysis of ADVENT. JACC Clin Electrophysiol, 2024, 10(7 Pt 2): 1634-1644.
20.	Gunawardene MA, Harloff T, Jularic M, et al. Contemporary catheter ablation of complex atrial tachycardias after prior atrial fibrillation ablation: pulsed field vs. radiofrequency current energy ablation guided by high-density mapping. Europace, 2024, 26(4): euae072.
21.	Kueffer T, Stettler R, Maurhofer J, et al. Pulsed-field vs cryoballoon vs radiofrequency ablation: outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation. Heart Rhythm, 2024, 21(8): 1227-1235.
22.	Maurhofer J, Kueffer T, Madaffari A, et al. Pulsed-field vs. cryoballoon vs. radiofrequency ablation: a propensity score matched comparison of one-year outcomes after pulmonary vein isolation in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol, 2024, 67(2): 389-397.
23.	Reinsch N, Füting A, Hartl S, et al. Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study). Europace, 2024, 26(7): euae194.
24.	Soubh N, Gronwald J, Haarmann H, et al. Next-generation atrial fibrillation ablation: clinical performance of pulsed-field ablation and very high-power short-duration radiofrequency. J Interv Card Electrophysiol, 2024, 67(9): 2067-2075.
25.	Wang J, Wang X, Liu W, et al. Efficacy, safety, and somatosensory comparison of pulsed-field ablation and thermal ablation: outcomes from a 2-year follow-up. J Interv Card Electrophysiol, 2024 Dec 14.
26.	刘铮, 左琨, 张婉菁, 等. 脉冲电场消融与射频消融治疗心房颤动的临床比较. 中华心律失常学杂志, 2024, 28(6): 496-504.
27.	Wörmann J, Schipper JH, Lüker J, et al. Comparison of pulsed-field ablation versus very high power short duration-ablation for pulmonary vein isolation. J Cardiovasc Electrophysiol, 2023, 34(12): 2417-2424.
28.	Yang M, Wang PY, Hao YL, et al. A real-world case-control study on the efficacy and safety of pulsed field ablation for atrial fibrillation. Eur J Med Res, 2023, 28(1): 519.
29.	Zhai Z, Ling Y, Wang Y, et al. Preclinical evaluation of reversible pulsed electrical field: electrophysiological and histological assessment of myocardium. Front Cardiovasc Med, 2024 Aug 1: 11: 1426920.
30.	Bradley CJ, Haines DE. Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation. J Cardiovasc Electrophysiol, 2020, 31(8): 2136-2147.
31.	Mercadal B, Vernier PT, Ivorra A. Dependence of electroporation detection threshold on cell radius: an explanation to observations non compatible with Schwan's equation model. J Membr Biol, 2016, 249(5): 663-676.
32.	Liu D, Li Y, Zhao Q. Effects of inflammatory cell death caused by catheter ablation on atrial fibrillation. J Inflamm Res, 2023 Aug 17: 16: 3491-3508.16-3491.
33.	Gottlieb LA, Dekker LRC, Coronel R. The blinding period following ablation therapy for atrial fibrillation: proarrhythmic and antiarrhythmic pathophysiological mechanisms. JACC Clin Electrophysiol, 2021, 7(3): 416-430.
34.	Chang R, Luo D, He W, et al. A novel method for septal reduction therapy by three-dimensional guided transvenous intraseptal pulsed-field ablation. Heart Rhythm, 2024, 21(3): 258-267.
35.	Fan S, Jia F, Cui Y, et al. Study on the process of cardiomyocyte apoptosis after pulsed field ablation. Front Cardiovasc Med, 2023, 10: 1112131.
36.	Yahsaly L, Siebermair J, Wakili R. Catheter ablation: developments and technique selection. Herzschrittmacherther Elektrophysiol, 2022, 33(1): 3-11.
37.	Kuroki K, Whang W, Eggert C, et al. Ostial dimensional changes after pulmonary vein isolation: pulsed field ablation vs radiofrequency ablation. Heart Rhythm, 2020, 17(9): 1528-1535.
38.	Bisignani A, Schiavone M, Solimene F, et al. National workflow experience with pulsed field ablation for atrial fibrillation: learning curve, efficiency, and safety. J Interv Card Electrophysiol, 2024, 67(9): 2127-2136.
39.	Reddy VY, Calkins H, Mansour M, et al. Pulsed field ablation to treat paroxysmal atrial fibrillation: safety and effectiveness in the AdmIRE pivotal trial. Circulation, 2024, 150(15): 1174-1186.
40.	Reddy VY, Gerstenfeld EP, Schmidt B, et al. Pulsed field ablation for persistent atrial fibrillation: 1-year results of ADVANTAGE AF. J Am Coll Cardiol, 2025, 85(17): 1664-1678.
41.	Calvert P, Kollias G, Pürerfellner H, et al. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace, 2023, 25(6): euad151.
42.	Georgiopoulos G, Tsiachris D, Kordalis A, et al. Pharmacotherapeutic strategies for atrial fibrillation in pregnancy. Expert Opin Pharmacother, 2019, 20(13): 1625-1636.
43.	Padula WV, Paffrath A, Jacobsen CM, et al. Comparing pulsed field ablation and thermal energy catheter ablation for paroxysmal atrial fibrillation: a cost-effectiveness analysis of the ADVENT trial. J Med Econ, 2025, 28(1): 127-135.

1. Antoun I, Layton GR, Nizam A, et al. Hypertension and atrial fibrillation: bridging the gap between mechanisms, risk, and therapy. Medicina (Kaunas), 2025, 61(2): 362.
2. Hu D, Barajas-Martinez H, Zhang ZH, et al. Advances in basic and translational research in atrial fibrillation. Philos Trans R Soc Lond B Biol Sci, 2023, 378(1879): 20220174.
3. Jiang X, Ling J, Xiong Q, et al. Global, regional, and national burden of atrial fibrillation/flutter related to metabolic risks over three decades: estimates from the global burden of disease study 2019. Eur Heart J Qual Care Clin Outcomes, 2024, 10(5): 391-401.
4. Ko D, Chung MK, Evans PT, et al. Atrial fibrillation: a review. JAMA, 2025, 333(4): 329-342.
5. Karnik AA, Saczynski JS, Chung JJ, et al. Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study. J Am Geriatr Soc, 2022, 70(10): 2818-2826.
6. Gao L, Nguyen D, Moodie M. Economic burden of dementia caused by cardiovascular disease in Australia. J Alzheimers Dis, 2022, 86(2): 601-612.
7. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2024, 45(36): 3314-3414.
8. Chan YH, Chao TF, Chen SW, et al. Clinical outcomes in elderly atrial fibrillation patients at increased bleeding risk treated with very low dose vs. regular-dose non-vitamin K antagonist oral anticoagulants: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother, 2023, 9(8): 681-691.
9. Pannone L, Mouram S, Della Rocca DG, et al. Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience. Europace, 2023, 25(5): euad114.
10. Kistler PM, Chieng D, Sugumar H, et al. Effect of catheter ablation using pulmonary vein isolation with vs without posterior left atrial wall isolation on atrial arrhythmia recurrence in patients with persistent atrial fibrillation: the CAPLA randomized clinical trial. JAMA, 2023, 329(2): 127-135.
11. Winkle RA, Mead RH, Engel G, et al. Very long term outcomes of atrial fibrillation ablation. Heart Rhythm, 2023, 20(5): 680-688.
12. Chun KJ, Miklavčič D, Vlachos K, et al. State-of-the-art pulsed field ablation for cardiac arrhythmias: ongoing evolution and future perspective. Europace, 2024, 26(6): euae134.
13. Batista Napotnik T, Polajžer T, Miklavčič D. Cell death due to electroporation: a review. Bioelectrochemistry, 2021, 141: 107871.
14. Schmidt B, Bordignon S, Neven K, et al. EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation: lessons from the multi-centre EU-PORIA registry. Europace, 2023, 25(7): euad185.
15. Calvert P, Mills MT, Xydis P, et al. Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: a real-world study. Heart Rhythm, 2024, 21(9): 1537-1544.
16. De Becker B, El Haddad M, De Smet M, et al. Procedural performance and outcome after pulsed field ablation for pulmonary vein isolation: comparison with a reference radiofrequency database. Eur Heart J Open, 2024, 4(2): oeae014.
17. Della Rocca DG, Marcon L, Magnocavallo M, et al. Pulsed electric field, cryoballoon, and radiofrequency for paroxysmal atrial fibrillation ablation: a propensity score-matched comparison. Europace, 2023, 26(1): euae016.
18. Dello Russo A, Compagnucci P, Anselmino M, et al. Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: results of a multicenter, real-world experience. Heart Rhythm, 2024, 21(9): 1526-1536.
19. Gerstenfeld EP, Mansour M, Whang W, et al. Autonomic effects of pulsed field vs thermal ablation for treating atrial fibrillation: subanalysis of ADVENT. JACC Clin Electrophysiol, 2024, 10(7 Pt 2): 1634-1644.
20. Gunawardene MA, Harloff T, Jularic M, et al. Contemporary catheter ablation of complex atrial tachycardias after prior atrial fibrillation ablation: pulsed field vs. radiofrequency current energy ablation guided by high-density mapping. Europace, 2024, 26(4): euae072.
21. Kueffer T, Stettler R, Maurhofer J, et al. Pulsed-field vs cryoballoon vs radiofrequency ablation: outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation. Heart Rhythm, 2024, 21(8): 1227-1235.
22. Maurhofer J, Kueffer T, Madaffari A, et al. Pulsed-field vs. cryoballoon vs. radiofrequency ablation: a propensity score matched comparison of one-year outcomes after pulmonary vein isolation in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol, 2024, 67(2): 389-397.
23. Reinsch N, Füting A, Hartl S, et al. Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study). Europace, 2024, 26(7): euae194.
24. Soubh N, Gronwald J, Haarmann H, et al. Next-generation atrial fibrillation ablation: clinical performance of pulsed-field ablation and very high-power short-duration radiofrequency. J Interv Card Electrophysiol, 2024, 67(9): 2067-2075.
25. Wang J, Wang X, Liu W, et al. Efficacy, safety, and somatosensory comparison of pulsed-field ablation and thermal ablation: outcomes from a 2-year follow-up. J Interv Card Electrophysiol, 2024 Dec 14.
26. 刘铮, 左琨, 张婉菁, 等. 脉冲电场消融与射频消融治疗心房颤动的临床比较. 中华心律失常学杂志, 2024, 28(6): 496-504.
27. Wörmann J, Schipper JH, Lüker J, et al. Comparison of pulsed-field ablation versus very high power short duration-ablation for pulmonary vein isolation. J Cardiovasc Electrophysiol, 2023, 34(12): 2417-2424.
28. Yang M, Wang PY, Hao YL, et al. A real-world case-control study on the efficacy and safety of pulsed field ablation for atrial fibrillation. Eur J Med Res, 2023, 28(1): 519.
29. Zhai Z, Ling Y, Wang Y, et al. Preclinical evaluation of reversible pulsed electrical field: electrophysiological and histological assessment of myocardium. Front Cardiovasc Med, 2024 Aug 1: 11: 1426920.
30. Bradley CJ, Haines DE. Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation. J Cardiovasc Electrophysiol, 2020, 31(8): 2136-2147.
31. Mercadal B, Vernier PT, Ivorra A. Dependence of electroporation detection threshold on cell radius: an explanation to observations non compatible with Schwan's equation model. J Membr Biol, 2016, 249(5): 663-676.
32. Liu D, Li Y, Zhao Q. Effects of inflammatory cell death caused by catheter ablation on atrial fibrillation. J Inflamm Res, 2023 Aug 17: 16: 3491-3508.16-3491.
33. Gottlieb LA, Dekker LRC, Coronel R. The blinding period following ablation therapy for atrial fibrillation: proarrhythmic and antiarrhythmic pathophysiological mechanisms. JACC Clin Electrophysiol, 2021, 7(3): 416-430.
34. Chang R, Luo D, He W, et al. A novel method for septal reduction therapy by three-dimensional guided transvenous intraseptal pulsed-field ablation. Heart Rhythm, 2024, 21(3): 258-267.
35. Fan S, Jia F, Cui Y, et al. Study on the process of cardiomyocyte apoptosis after pulsed field ablation. Front Cardiovasc Med, 2023, 10: 1112131.
36. Yahsaly L, Siebermair J, Wakili R. Catheter ablation: developments and technique selection. Herzschrittmacherther Elektrophysiol, 2022, 33(1): 3-11.
37. Kuroki K, Whang W, Eggert C, et al. Ostial dimensional changes after pulmonary vein isolation: pulsed field ablation vs radiofrequency ablation. Heart Rhythm, 2020, 17(9): 1528-1535.
38. Bisignani A, Schiavone M, Solimene F, et al. National workflow experience with pulsed field ablation for atrial fibrillation: learning curve, efficiency, and safety. J Interv Card Electrophysiol, 2024, 67(9): 2127-2136.
39. Reddy VY, Calkins H, Mansour M, et al. Pulsed field ablation to treat paroxysmal atrial fibrillation: safety and effectiveness in the AdmIRE pivotal trial. Circulation, 2024, 150(15): 1174-1186.
40. Reddy VY, Gerstenfeld EP, Schmidt B, et al. Pulsed field ablation for persistent atrial fibrillation: 1-year results of ADVANTAGE AF. J Am Coll Cardiol, 2025, 85(17): 1664-1678.
41. Calvert P, Kollias G, Pürerfellner H, et al. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace, 2023, 25(6): euad151.
42. Georgiopoulos G, Tsiachris D, Kordalis A, et al. Pharmacotherapeutic strategies for atrial fibrillation in pregnancy. Expert Opin Pharmacother, 2019, 20(13): 1625-1636.
43. Padula WV, Paffrath A, Jacobsen CM, et al. Comparing pulsed field ablation and thermal energy catheter ablation for paroxysmal atrial fibrillation: a cost-effectiveness analysis of the ADVENT trial. J Med Econ, 2025, 28(1): 127-135.

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Latest ArticlesEfficacy and safety of pulsed field ablation versus radiofrequency ablation for atrial fibrillation: A systematic review and meta-analysis

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