Pulsed Field Ablation for Atrial Fibrillation: A Systematic Review of Efficacy, Safety, and Durability

Abstract

Background and Purpose: Pulsed field ablation (PFA) has emerged as a nonthermal energy source for atrial fibrillation (AF) ablation, utilizing ultra-short, high-voltage electrical pulses to selectively ablate myocardial tissue while minimizing collateral injury. Growing evidence from prospective and randomized studies suggests that PFA may offer comparable efficacy and superior safety to conventional thermal ablation. This systematic review synthesizes contemporary data evaluating the clinical performance and long-term outcomes of PFA.

Methods: A systematic literature search of major cardiovascular databases and journals through 2025 identified prospective trials, randomized controlled studies, and multicenter registries assessing PFA in paroxysmal and persistent AF. Data on procedural metrics, arrhythmia-free survival, lesion durability, and safety outcomes were extracted and qualitatively synthesized.

Results: Across more than 18,000 patients, PFA achieved high procedural success with acute pulmonary vein isolation in nearly all cases. One-year freedom from atrial arrhythmia ranged between 66% and 84% in paroxysmal AF and 55% and 80% in persistent AF. Continuous monitoring demonstrated significant reductions in arrhythmia burden and durable lesion formation exceeding 90% in optimized waveform systems. Major adverse events were uncommon, with a safety event rate below 2%, and virtually no reports of esophageal injury, pulmonary vein stenosis, or persistent phrenic nerve palsy. Rare complications included transient coronary spasm (≈0.1%) and pericardial tamponade (<0.5%). Long-term follow-up beyond four years demonstrated sustained rhythm control in approximately 73% of patients.

Conclusions: Pulsed field ablation provides effective, durable rhythm control with an exceptional safety margin compared to thermal modalities. These findings position PFA as a transformative advance in AF ablation, combining efficacy, procedural efficiency, and tissue selectivity. Ongoing studies will clarify long-term performance and guide standardization across evolving PFA technologies.