Phrenic nerve and esophageal injury in pulsed field ablation versus radiofrequency and cryoablation

Abstract

Background: Phrenic nerve injury (PNI) and esophageal injury are serious complications associated with atrial fibrillation (AF) ablation procedures. Pulsed field ablation (PFA), a non- thermal modality, has emerged as a promising alternative to conventional thermal ablation techniques, such as radiofrequency ablation (RFA) and cryoballoon ablation (CBA).

Objective: To evaluate and compare the incidence of PNI and esophageal injury following PFA, RFA, and CBA in patients undergoing AF ablation.

Methods: A systematic search of The Cochrane Library, MEDLINE, and EMBASE databases was conducted for studies published between 2014 and 2024. Cohort and case-control studies comparing PFA with RFA and/or CBA in relation to PNI and esophageal injury were included. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results: Eleven studies involving 4,603 patients were included in the analysis. The incidence of PNI was 0.23% with PFA, 0.63% with RFA, and 2.68% with CBA, respectively. A meta-analysis of five studies comparing PFA and CBA showed a significantly lower risk of PNI with PFA (RR 0.13, 95% CI 0.04–0.35; p < 0.0001). No esophageal injury was reported in the PFA group, compared to 2.79% in the RFA group and 1.45% in the CBA group. Pooled analysis demonstrated that PFA significantly reduced the risk of esophageal injury compared to RFA (RR 0.06, 95% CI 0.01–0.29; p = 0.0005) and CBA (RR 0.07, 95% CI 0.01–0.39; p = 0.002).

Conclusion: PFA is associated with a significantly lower risk of phrenic nerve and esophageal injury than RFA and CBA.