Pulsed-field ablation versus thermal ablation in the management of atrial fibrillation: A narrative review.

backgroundAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, contributing significantly to morbidity, mortality, and healthcare costs. Pulmonary vein isolation (PVI) via catheter ablation is a cornerstone therapy for symptomatic patients. Conventional thermal methods-radiofrequency and cryoballoon ablation-are well-established but carry risks of non-target tissue injury, including esophageal damage, phrenic nerve palsy, and pulmonary vein stenosis. Pulsed-field ablation (PFA) is a novel non-thermal modality that uses irreversible electroporation for enhanced tissue specificity, potentially improving safety and procedural efficiency.

objectivesThis narrative review evaluates PFA compared with conventional thermal ablation, contrasting mechanisms, clinical efficacy, safety profiles, procedural characteristics, and considerations for patient selection in AF management. Emerging evidence on procedural workflow and short-term clinical outcomes is also discussed.

methodsRecent clinical trials, registries, and meta-analyses were narratively reviewed. English-language, peer-reviewed studies published in the past 5 years in PubMed and Google Scholar reporting clinical outcomes, procedural safety, and workflow metrics were included, with a qualitative synthesis comparing PFA to radiofrequency and cryoballoon ablation. KEY

findingsPFA demonstrates non-inferiority to thermal ablation in achieving acute PVI success and comparable one-year freedom from arrhythmia. Advantages include reduced procedure and fluoroscopy times, a shorter learning curve, and potentially lower anesthetic requirements. Its non-thermal mechanism is associated with a lower incidence of oesophageal injury and phrenic nerve dysfunction in available clinical series. While its role in persistent AF and complex substrate modification is under investigation, evidence in these populations remains limited and varies across PFA platforms.

conclusionPFA offers safety and efficacy comparable to thermal ablation, with improved procedural efficiency. However, long-term durability data are still evolving, and further randomised studies are required before its role in complex AF ablation strategies and guideline recommendations can be fully defined.