Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Background: Pulmonary vein isolation (PVI) is a cornerstone treatment for atrial fibrillation (AF). Pulsed-field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency (RF) ablation are emerging technologies, but their comparative efficacy and safety remain unclear.

Objectives: To assess the efficacy and safety of PFA compared to vHPSD RF ablation for AF.

Methods: A systematic search of PubMed, Embase, Web of Science, and Cochrane databases identified studies comparing PFA and vHPSD ablation. Outcomes included PVI success, skin-to-skin procedure time, fluoroscopy time, freedom from atrial arrhythmias, and complications such as cardiac tamponade, stroke, and vascular access events. Continuous outcomes were analyzed using mean differences (MD), while binary outcomes were assessed with risk ratios (RR) and 95% confidence intervals (CI). A significance threshold of p < 0.05 was considered for statistical analyses. This study is registered in PROSPERO (CRD42024619301).

Results: Four observational studies with 605 patients were included, of whom 315 (52%) underwent PFA. PFA and vHPSD achieved similar PVI success (RR 1.00; 95% CI 0.99-1.01; p = 1). PFA reduced procedure time (MD -30.07 min; 95% CI -31.41 to -28.74; p<0.01) but increased fluoroscopy time (MD 6.87 min; 95% CI 3.66-10.08; p<0.01). Freedom from atrial arrhythmias was comparable (RR 1.03; 95% CI 0.94-1.14; p=0.5). Complication rates, including cardiac tamponade, stroke, and vascular access issues, showed no significant differences between groups.

Conclusion: PFA significantly shortens procedure time but requires longer fluoroscopy compared to vHPSD. Both techniques exhibit comparable efficacy for PVI and arrhythmia freedom, with similar safety profiles.