Pulsed Field Ablation versus Thermal Ablation for Pulmonary Vein Isolation: A Network Meta-Analysis of Randomized Controlled Trials

Background and aims: Pulsed field ablation (PFA) has recently emerged as a promising alternative to conventional energy sources (ES) for atrial fibrillation (AF) ablation. However, comparative data between PFA and other ES-such as radiofrequency (RFA), cryoballoon (CBA), and laser balloon ablation (LBA)-remain limited.This network meta-analysis (CRD420251054760) aimed to compare outcomes of PFA versus thermal ES for AF ablation. Methods: A systematic network metanalysis using PubMed, Cochrane and EMBASE from inception to March 2026 was performed. Randomized controlled trials comparing different ES in first-attempt pulmonary vein isolation were included. Data extraction was performed according to PRISMA guidelines. The primary outcome was the recurrence of any sustained atrial tachyarrhythmia (ATA) at 12-month follow-up. Safety and efficiency outcomes were also compared among groups. Results: We included 18 studies, encompassing 4,162 patients. Compared to PFA, thermal ablation technologies showed a higher risk of ATA recurrence at 12-month follow-up (RFA: RR of 1.48 (95% CI 1.10-2.00); CBA: 1.43 (95% CI 1.07-1.92); LBA: RR 1.29 (CI 95% 0.84; 1.98)). PFA exhibited lowest procedural time among transcatheter ES, whereas RFA displayed a significantly lower fluoroscopy time. No significant differences were recorded for major periprocedural complications. A subgroup analysis restricted to studies involving only paroxysmal AF patients, as well as those employing contemporary technologies, yielded consistent findings. Conclusions: The present data indicate that, in patients undergoing a first transcatheter AF ablation, PFA may be associated with favourable efficacy and procedural efficiency compared with traditional thermal technologies, while showing a broadly comparable safety profile.