Comparing efficacy and safety between pulsed field ablation, cryoballoon ablation and high-power short duration radiofrequency ablation in atrial fibrillation: a systematic review and network meta-analysis

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Abstract
Background Pulsed field ablation (PFA) and high-power short-duration radiofrequency ablation (HPSD) are emerging techniques for treating atrial fibrillation (AF), offering promising results compared to cryoballoon ablation (CBA). This network meta-analysis aims to evaluates the efficacy and safety of PFA, HPSD, and CBA. Method PubMed, Scopus and Cochrane Central Register of Controlled Trials were systematically searched for relevant studies until October 2024. The primary outcome is freedom from atrial arrhythmia. A random-effects model was used for data synthesis, and P-scores were employed for outcome ranking. Point estimation (odd ratios) was calculated for comparisons. Results Eighteen studies were included in our network meta-analysis, involving 7,071 atrial fibrillation patients. Among them, 2,023 (29%), 3,725 (53%), and 1,323 (18%) patients underwent PFA, CBA, and HPSD, respectively. PFA demonstrated a higher freedom from atrial arrhythmia, with an odds ratio (OR) of 3.63 (95% CI: 2.95–4.46) compared to CBA and 1.89 (95% CI: 1.47–2.43) compared to HPSD. However, PFA was associated with a higher risk of complications (OR = 6.54, 95% CI: 2.13–20.00) compared to CBA, while HPSD showed an insignificant association with a lower risk of complications compared to CBA (OR = 0.61, 95% CI: 0.15–2.42). PFA had the shortest procedural time (P-score: 100%), while HPSD had the longest (P-score: 0%). In contrast, HPSD had the shortest fluoroscopic time, with P-scores of 100%, 46%, and 3% for HPSD, PFA, and CBA, respectively. Conclusion PFA demonstrated higher efficacy but also a higher risk of complications compared to HPSD and CBA. HPSD showed greater efficacy with comparable safety to CBA. Graphical abstract

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