Pulsed Field Ablation Versus Cryoballoon Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background and Aims: Atrial fibrillation (AF) is the most common sustained arrhythmia, with pulmonary vein isolation (PVI) via catheter ablation serving as a key rhythm control strategy. Cryoballoon ablation (CBA) is established, but pulsed field ablation (PFA), a non-thermal technique, promises enhanced safety and efficiency. This meta-analysis aims to compare PFA and CBA in adults undergoing first-time PVI for paroxysmal or persistent AF, evaluating acute procedural success, safety (e.g., phrenic nerve palsy, tamponade), and 1-year arrhythmia-free survival, with subgroup analyses by AF type. Methods : Conducted per PRISMA guidelines and registered on PROSPERO (ID: CRD420251139409), we searched PubMed, Embase, Web of Science, and others from inception to August 2025. Included were RCTs and observational studies comparing PFA and CBA with extractable data on key outcomes. Quality was assessed via Newcastle-Ottawa Scale and GRADE. Random-effects models in RevMan 5.4 pooled mean differences (MD) for continuous outcomes and odds/risk ratios (OR/RR) for dichotomous ones, with heterogeneity via I 2 . Results: Seven studies were included. PFA showed shorter procedure time (MD -15.24 min, 95% CI -16.63 to -13.85; P<0.00001; I 2 =89%) and no difference in fluoroscopy time (MD -0.06 min, 95% CI -0.45 to 0.33; P=0.77; I 2 =94%). Freedom from arrhythmia was higher with PFA (OR 1.27, 95% CI 1.04-1.55; P=0.02; I 2 =45%), and phrenic nerve palsy lower (RR 0.17, 95% CI 0.04-0.63; P=0.008; I 2 =0%). No differences in cardiac tamponade (OR 2.11, 95% CI 0.80-5.57; P=0.13; I 2 =0%), repeat ablation (OR 0.84, 95% CI 0.65-1.09; P=0.18; I 2 =75%), or vascular complications (OR 0.96, 95% CI 0.32-2.94; P=0.96; I 2 =0%). Subgroups by AF type were consistent. GRADE certainty was low to very low. Conclusion: PFA offers procedural advantages and reduced phrenic injury over CBA, with superior arrhythmia control, though evidence quality is limited. Large RCTs are needed for confirmation.

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