A network meta-analysis of comparative effectiveness and safety of pulsed field, radiofrequency, and cryoballoon ablation for atrial fibrillation.

BACKGROUND

Pulsed field ablation (PFA) has emerged as a non-thermal alternative to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) for atrial fibrillation (AF). Despite several individual comparisons, integrated comparison across 3 modalities remains limited.

OBJECTIVE

To compare the efficacy, safety, and procedural characteristics of PFA, RFA, and CBA for AF ablation.

METHODS

We performed frequentist network meta-analysis (using pooled odds ratios [ORs] and mean differences[MDs]) of studies comparing PFA, RFA, and CBA. Outcomes included recurrence of atrial arrhythmias, AF recurrence, atrial tachycardia (AT)/atrial flutter (AFL) recurrence, peri-procedural complications, pericardial complications, procedure time, and fluoroscopy time.

RESULTS

Thirty-four studies involving 6961 patients were included. PFA demonstrated lower atrial arrhythmia recurrence compared with RFA (OR 0.71) and CBA (OR 0.83), while CBA was superior to RFA (OR 0.85). Among paroxysmal AF patients, PFA demonstrated lower atrial arrhythmia recurrence than RFA (OR 0.62) and CBA (OR 0.57), while CBA and RFA were comparable. For AF recurrence, PFA demonstrated lower risk compared with RFA (OR 0.56) and CBA (OR 0.62), while CBA and RFA were comparable. AT/AFL recurrence was similar between PFA and other modalities, while CBA showed lower recurrence risk than RFA (OR 0.48). Overall peri-procedural complications were comparable. CBA had fewer pericardial complications than RFA (OR 0.27) and PFA (OR 3.23). PFA had shorter procedure times than RFA (MD -30.8 min) and CBA (MD -14.25 min), but longer fluoroscopy times versus RFA (MD +6.8 min) and CBA (MD +3.9 min).

CONCLUSION

PFA demonstrates favorable efficacy and shorter procedure times with similar overall safety.