Efficacy and Safety of Pulsed-Field Versus High-Power Short-Duration Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data.

Background: Pulsed-field ablation (PFA) and high-power short-duration (HPSD) ablation (45-90 W) are emerging technologies in atrial fibrillation (AF) treatment, both achieving durable pulmonary vein isolation. We aim to investigate the efficacy and safety of PFA versus HPSD ablation.

Methods: We comprehensively searched PubMed, Web of Science (WOS), Scopus, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) through July 2024. Pairwise meta-analysis with reconstructed time-to-event analysis were performed using R version 4.3.1 (PROSPERO ID: CRD42024576031).

Results: Seven observational studies, including 1904 patients, were included. PFA was significantly associated with lower atrial tachyarrhythmia recurrence compared to HPSD ablation (45-90 W) at the longest follow-up (RR: 0.73, 95% CI [0.60, 0.88], p < 0.01). Subgroup analysis revealed a significant reduction in atrial tachyarrhythmia recurrence with PFA versus HPSD ablation (45-50 W) (RR: 0.69, 95% CI [0.54, 0.88], p < 0.01), but not compared to vHPSD ablation (70-90 W). Reconnected pulmonary vein rates were significantly lower with PFA compared to HPSD (45-50 W) (p = 0.03), while no significant difference was observed compared to vHPSD (70-90 W). PFA was significantly associated with reduced procedural duration (MD: -33.15 with 95% CI [-40.93, -25.36], p < 0.01) and left atrial dwell time (MD: -32.16 with 95% CI [-45.55, -18.77], p < 0.01), although fluoroscopy time increased (MD: 7.48 with 95% CI [4.29, 10.68], p < 0.01) compared to HPSD ablation (45-90 W). Safety profiles were comparable, but pericarditis rates were significantly lower with PFA versus HPSD (45-50 W) (p = 0.003) and vHPSD (70-90 W) (p = 0.019). Kaplan-Meier analysis showed a 28% lower risk of atrial tachyarrhythmia recurrence with PFA compared to HPSD ablation (45-90 W) (HR: 0.72, 95% CI [0.57, 0.91], p = 0.006) over an 18-month follow-up.

Conclusion: PFA and HPSD ablation (45-90 W) are effective and safe for AF ablation. PFA was significantly associated with lower atrial tachyarrhythmia recurrence, shorter procedural duration, reduced left atrial dwell time, increased fluoroscopy time, and comparable safety, with lower rates of pericarditis compared to HPSD ablation.