Intravascular Haemolysis and Acute Kidney Injury Following Pulsed Field Ablation: A Systematic Review and Meta-Analysis.

BACKGROUND & AIMS: Despite atrial fibrillation ablation showing promise, recent studies have described the potential induction of haemolysis and onset of acute kidney injury (AKI) caused by pulsed field ablation (PFA) raising safety concerns. This study aimed to evaluate the changes in haemolysis and renal function biomarker following the ablation.

METHODS

We systematically searched PubMed, ScienceDirect, and Cochrane Library for observational and randomised controlled trials up to 16 July 2025. We calculated the changes using the difference between pre- and post-ablation biomarker levels. Generic inverse variance was used with 95% confidence interval (CI). Data measures were mean difference (MD) and pooled using a random effects model.

RESULTS

Ten observational studies with 1,292 patients were included. PFA is associated with haemolysis reflected on significant increase in lactate dehydrogenase (MD -123.63, 95% CI -194.54 to -52.71), bilirubin (MD -0.82, 95% CI -1.44 to -0.20), and free plasma haemoglobin (MD -47.50, 95% CI -62.36 to -32.65) together with a reduction of haptoglobin (MD 0.58, 95% CI 0.23 - 0.94) following the ablation resulting reduced red blood cell (MD 0.19, 95% CI 0.03 to 0.35), haemoglobin (MD 0.99, 95% CI 0.62 to 1.36), and haematocrit (MD 2.79, 95% CI 1.10 to 4.49). However, there were no difference in urea (MD -0.20, 95% CI -1.17 to 0.77), creatinine (MD -0.07, 95% CI -0.14 to 0.00), and estimated glomerular filtration rate (MD -2.63, 95% CI -6.65 to 1.39).

CONCLUSIONS

Despite significant haemolysis-related biomarker changes after PFA, no clinically meaningful anaemia occurred, and AKI was rare and transient. Renal risk appears to depend on application and baseline renal vulnerability, while post-ablation hydration may serve as a preventive strategy against AKI. Further optimisation of PFA and peri-procedural management is needed to enhance safety.