Pulsed field ablation vs high-power short duration/very high-power short duration pulmonary vein isolation-Systematic review and meta-analysis with Kaplan-Meier reconstructed individual patient data

Abstract

BACKGROUND High-power/very high-power short-duration (HPSD/VHPSD) pulmonary vein isolation has greater efficacy than does conventional pulmonary vein isolation, while pulsed field ablation (PFA) is associated with a significantly shorter procedural duration with comparable efficacy. OBJECTIVE This meta-analysis compared the efficacy, procedural duration, and safety of PFA vs HPSD/VHPSD ablation. METHODS Atrial tachyarrhythmia (ATa) recurrence was defined as any episode of atrial fibrillation, flutter, or tachycardia lasting >30 seconds, detected by Holter monitoring or electrocardiography, after a 3-month blanking period. The intervention group received PFA and the control group received HPSD/VHPSD ablation. RESULTS Eight studies (mostly retrospective observational) comprising 1411 patients were analyzed. ATa recurrence occurred less frequently in the PFA group than in the HPSD/VHPSD ablation group (15% in PFA vs 25% in HPSD/VHPSD ablation; odds ratio 0.57; 95% confidence interval [CI] 0.40-0.81; P = .002; I2 = 31.4%, P = .374). Meta-regression analysis indicated that the benefit of PFA was not significantly influenced by paroxysmal atrial fibrillation, sex, age, hypertension, or left ventricular ejection fraction. Reconstructed Kaplan-Meier curves showed greater freedom from ATa recurrence in the PFA group, and subsequent reconstructed individual patient data Cox regression analysis showed a lower hazard ratio (hazard ratio 0.68; 95% CI 0.48-0.97; P = .033). Pulmonary vein reconnection rates were comparable (32% in PFA vs 35% in HPSD/VHPSD ablation; odds ratio 0.84; 95% CI 0.53-1.34; P = .473). PFA significantly reduced total procedural duration (mean difference-29.67 minutes; 95% CI-38.31 to-21.03 minutes; P < .001). Complications rates were similar between the 2 groups. CONCLUSION PFA was potentially associated with a comparable or reduced ATa recurrence rate and a shorter procedural duration compared with HPSD/VHPSD ablation while maintaining similar complication rates. Further randomized controlled trials are warranted to validate these findings. PROSPERO REGISTRATION NUMBERCRD420251034443.