Pulsed Field Ablation Versus Thermal Ablation for First-Time Pulmonary Vein Isolation in Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: With over 60 million cases worldwide, atrial fibrillation (AF) is one of the most common cardiac arrhythmias in adults. Pulsed-field ablation (PFA) has emerged as a significant alternative to thermal ablation for pulmonary vein isolation (PVI). This systematic review and meta-analysis investigated the efficacy and safety of PFA versus thermal ablation in patients undergoing first-time PVI. METHODS: We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library from inception to 2025. Hazard ratios (HRs) with 95% confidence intervals (CIs) were derived from reconstructed Kaplan-Meier survival curves to compare atrial tachyarrhythmia recurrence between PFA and thermal ablation. Random-effects models were used to compare AF recurrence, durable PVI, redo procedures, phrenic nerve palsy (PNP), and other safety outcomes between the two groups. RESULTS: A total of 27 studies comprising 8546 patients were included. Kaplan-Meier reconstruction from ten studies demonstrated higher 12-month arrhythmia-free survival with PFA compared with thermal ablation (78.4% [95% CI, 76.1-80.8] vs. 73.4% [95% CI, 71.5-75.4]). Thermal ablation was associated with a significantly higher risk of atrial tachyarrhythmia recurrence (HR 1.28, 95% CI 1.10-1.48; p = 0.001). Subgroup analyses demonstrated that PFA significantly reduced the recurrence risk in patients with paroxysmal AF (HR 1.63, 95% CI 1.31-2.03; p < 0.001), whereas no significant difference was observed in those with persistent AF (HR 1.13, 95% CI 0.92-1.41; p = 0.25). CONCLUSIONS: PFA was associated with lower rates of atrial tachyarrhythmia and AF recurrence rates than thermal ablation in patients undergoing first-time PVI; however, these findings should be interpreted cautiously, given the predominance of observational studies.