Pulsed-field ablation (PFA) is a nonthermal ablation method for pulmonary-vein isolation to treat atrial fibrillation. Limited data are available to compare PFA with cryoballoon ablation (CBA). We searched PubMed, Cochrane, and Embase for studies comparing PFA and CBA with at least one outcome of interest. Data analysis was performed using Cochrane RevMan 5.4. Dichotomous variables were compared using the Mantel-Haenszel method in a random-effects model to calculate the risk ratio and 95% confidence intervals (CI). Continuous variables were compared using the inverse variance method in a random-effects model to calculate standard mean differences (SMD) and 95% CI. Twenty-one studies comprising 5,222 patients (2,297:PFA, 2,925:CBA) were included. Thirteen studies reported AF recurrence after the blanking period of 3 months, with a lower pooled risk seen in PFA (RR 0.81; 95% CI: 0.70, 0.92). Sixteen studies reported a periprocedural complications rate with a lower pooled risk in PFA than in CBA (RR: 0.67; 95% CI: 0.45, 1.00). Eighteen studies reported procedural time, which was lower with PFA (SMD–0.57; 95% CI: 0.88,–0.26). However, fluoroscopy time was higher with PFA (SMD: 0.26; 95% CI: 0.06, 0.46) (15 studies). Three studies reported an increase in high-sensitivity troponin, with higher levels after PFA (SMD: 2.05; 95% CI: 0.50, 3.61). A greater decrease in heart rate was observed in the PFA group postprocedure (SMD:–0.97; 95% CI:–1.73,–0.21) (4 studies). The use of PFA is associated with lower AF recurrence rates, shorter procedure durations, and a more significant decrease in heart rate compared to CBA. The fluoroscopy times are higher with PFA, and periprocedural complication rates are similar to those with CBA.
Pulmonary vein isolation (PVI) is the cornerstone of catheter-based rhythm-control strategies in patients with symptomatic, drug-refractory atrial fibrillation (AF). Among thermal energy-based modalities, cryoballoon ablation (CBA) has emerged as a widely adopted, single-shot technique capable of delivering consistent circumferential PVI. However, despite its success, CBA carries the risk of rare but serious complications such as atrio-esophageal fistula and phrenic nerve palsy due to nonspecific thermal tissue injury. , Pulsed-field ablation (PFA) represents a paradigm shift, employing ultrashort, high-voltage electrical pulses to induce nonthermal irreversible electroporation, which selectively targets myocardial tissue. Preclinical and early clinical studies have demonstrated durable lesion formation and an exceptional safety profile, as it spares noncardiac structures, including the esophagus, phrenic nerves, and vasculature. , Recent clinical investigations suggest that PFA achieves comparable acute efficacy and midterm success rates to traditional thermal modalities, while reducing procedure duration and potentially minimizing complications. However, large-scale, head-to-head comparisons between PFA and next-generation CBA systems with respect to clinical efficacy, procedural efficiency, radiation exposure, and safety outcomes are still limited.
Methods
Search strategy and study selection
We conducted a systematic literature search across 3 major databases: PubMed, Cochrane Library, and Embase to identify clinical studies comparing pulsed-field ablation (PFA) and cryoablation (CBA) in the management of atrial fibrillation (AF). We used the following keywords in our search: “pulsed field ablation,” “catheter ablation,” “cryoballoon ablation,” “cryothermal,” “cryoablation,” and “atrial fibrillation.” In addition, we manually reviewed the reference lists of relevant articles and screened proceedings from recent major cardiovascular conferences to identify any additional studies that may have been missed in the initial search. The search included articles published up to the time of analysis and was limited to studies reporting at least one of the following outcomes: AF recurrence after a 3-month blanking period, periprocedural complication rate, procedural duration, fluoroscopy time, postablation troponin elevation, or changes in heart rate. Case reports, case series, nonhuman studies, editorials, and reviews were excluded.
Inclusion criteria
Observational studies and randomized controlled trials were included if they:
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Directly compared clinical outcomes between PFA and CBA in adult patients with AF.
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Reported on at least one of the specified outcomes.
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Provided sufficient data to extract effect estimates.
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Published in English.
Data extraction and synthesis
Two independent reviewers extracted data on study design, patient characteristics, sample size, ablation modality, and outcome measures. Discrepancies were resolved through consensus or consultation with a third reviewer.
Statistical analysis
Meta-analysis was performed using Cochrane Review Manager (RevMan) version 5.4. For dichotomous outcomes (e.g., AF recurrence, complication rates), we used the Mantel-Haenszel method in a random-effects model to compute risk ratios (RRs) with 95% confidence intervals (CIs). For continuous variables (e.g., procedural time, fluoroscopy time, troponin levels, heart rate change), we used the inverse variance method in a random-effects model to calculate standardized mean differences (SMDs) and corresponding 95% CIs. Statistical heterogeneity was assessed using the I² statistic, with I² >50% indicating moderate to high heterogeneity. Risk of bias was assessed using the RoB 2 tool for RCTs and the ROBINS-I tool for observational studies ( Supplementary Figure S1 ). Sensitivity analysis was also performed using ReVMan ( Supplementary Table S1 ). The central illustration was created using Biorender.com ( Central Illustration ).
Created with Biorender.com. AF-atrial fibrillation, PFA-pulsed field ablation, CBA-cryoballoon ablation, HR-heart rate
Results
Study characteristics
The PRISMA flow chart describes the search strategy ( Figure 1 ). A total of 21 studies encompassing 5,222 patients were included in the final analysis. Of these, 2,297 patients underwent pulsed-field ablation (PFA) and 2,925 patients underwent cryoballoon ablation (CBA). The studies were published between 2021 and 2025, ,,,,,,,,,,,,,,,,,,,, comprising 19 observational studies (12 prospective cohort, ,,,,,,,,,,, 6 retrospective cohort, ,,,,, and 1 cross-sectional study ), along with 2 RCTs. , The studies varied in size and design, but all provided comparative outcome data for at least 1 variable of interest. Tables 1 , 2 and 3 present the patient demographics, comorbidities, and procedural complications, respectively .
PRISMA flow chart.
Table 1
Patient demographics
| Study, year | N | Age, years | Male, % | PAF, % | BMI, kg/m 2 | LAD, mm | LVEF, % | Follow-up duration, months |
|---|---|---|---|---|---|---|---|---|
| Badertsche 2023 | 106/75 | 65/64 | 63/64 | 61/68 | 27 ± 3.7/ 27 ± 3.7 | 41 ± 6.4/ 40 ± 6.3 | 57 ± 8.6/ 58 ± 9.1 | 13 |
| Blockhaus 2023 | 23/20 | 57/59 | 65/80 | 52/50 | 28 ± 4/ 26 ± 4 | 41 ± 3/ 41 ± 3 | 56 ± 8/ 55 ± 8 | 12 |
| Cochet 2021 | 18/7 | 58/NR | 83/NR | 100/100 | NR | NR | 62 ± 6/NR | 3 |
| Krisai 2022 | 20/20 | 70.6/64.7 | NR | 55/60 | NR | 38.9/39.3 | NR | Ѱ |
| Kupusovic 2023 | 15/11 | 65.3/65.1 | 66.7/100 | 60/36.4 | 28.8 ± 4.9/ 27.9 ± 4.5 | NR | 52.7 ± 8.8/ 55.2 ± 5.7 | 6 |
| Lemoine 2023 | 51/40 | 68/63 | 71/65 | 41/47 | 27 ± 5/ 28 ± 5 | NR | 52 ± 12/ 53 ± 9 | Ѱ |
| Monte 2023 | 40/36 | 60.2/60.1 | 60/67 | 100/100 | 26.5 ± 0.7/ 26.8 ± 0.9 | NR | 59.6 ± 2.4/ 59.1 ± 5.2 | Ѱ |
| Musikantow 2022 | 40/40 | 59/60 | 77/77 | 100/100 | NR | 44 ± 4/ 48 ± 11 | 63.1 ± 5.4/ 57.6 ± 12.7 | 3 |
| Maurhofer 2023 | 40/80 | 62.6/62.2 | 75/72.5 | 100/100 | 25.9 ± 3.9/ 26.2 ± 3.4 | 42.0 ± 5.8/ 42.0 ± 5.2 | 60.0 ± 3.7/ 60.0 ± 6.8 | 12.8 |
| Meininghaus 2023 | 20/33 | 71.5/65.8 | 70/52 | 35/48.5 | 28.3 ± 3.3/ 29.1 ± 5.3 | 46.0 ± 5.2/ 43.0 ± 3.3 | NR | PFA-9 CBA-27 |
| Reddy 2023 | 305/135 | 62.4/62.4 | 66.2/61.5 | 100/100 | 28.3 ± 4.6/ 28.3 ± 4.6 | 38.8 ± 5.7/ 40.0 ± 5.7 | NR | 12 |
| Schipper 2023 | 54/54 | 69/67 | 69/69 | 30/31 | 27.8 ± 5.0/ 28.1 ± 4.5 | 38.8 ± 5.8/ 39.6 ± 6.1 | 53.3 ± 10.9/ 54.9 ± 10.6 | 8.9 |
| Tohoku 2023 | 54/43 | 69/69 | 60/43 | 59/58 | 28 ± 5/ 28 ± 6 | 40.5 ± 5.9/ 39.5 ± 7.0 | 60.8 ± 7.2/ 59.1 ± 13.4 | 10.7 |
| Urbanek 2023 | 200/200 | 71/68 | 59/54 | 58/63.5 | 27 ± 5.2/ 27 ± 4.4 | 41 ± 6.7/ 40 ± 5.9 | NR | 12 |
| Van de Kar 2023 | 473/1241 | 65/64 | 63.6/69.2 | 61/66 | 26.8 ± 3.7/ 26.8 ± 3.7 | NR | 55 ± 7.4/ 55 ± 7.4 | 6 |
| Wahedi 2023 | 50/50 | 67/65 | 64/58 | 72/58 | 26.2 ± 3.5/ 26.2 ± 3.5 | 41.5 ± 6.3/ 42.5 ± 7.6 | NR | Ѱ |
| Chaumont 2024 | 151/150 | 61/63 | 62/62 | 74/73 | 27.1 ± 4.6/ 26.9 ± 4.2 | NR | NR | 12.8 |
| Kueffer 2024 | 214/190 | 69/68.2 | 76.6/72.6 | 0/0 | 28.1 ± 5.5/ 29.0 ± 5.6 | NR | 55 ± 11/ 55 ± 11 | 9.4 |
| Rattka 2024 | 94/47 | 63/64 | 61.7/53.2 | 56/51 | NR | NR | 55 ± 8.9/ 55 ± 3.7 | 12 |
| Rocca 2024 | 174/348 | 62/61.3 | 63.2/59.7 | 100/100 | 27 ± 4.8/ 27.4 ± 5.0 | 41.8 ± 4.9/ 41.3 ± 4.8 | 59.4 ± 4.2/ 56.4 ± 9.1 | ∼12 |
| Reichlin 2025 | 105/105 | 64/63 | 73/70 | 100/100 | 27.0 ± 3.9/ 27.3 ± 4.7 | 38 ± 6 | 60 ± 7/ 60 ± 6 | 12 |
Data presented as pulsed field ablation group/cryoballoon ablation group.
Abbreviations: N = number; BMI = body mass index; LAD = left atrial diameter; LVEF = left ventricular ejection fraction; NR = not reported; PAF = paroxysmal atrial fibrillation; Ѱ = no follow up; PFA = pulsed field ablation; CBA = cryoballoon ablation.
Table 2
Patient comorbidities
| Study, year | CHA 2 DS 2 -VASc | HTN, % | DM, % | Stroke/TIA, % | CAD, % | CHF, % | HLD, % |
|---|---|---|---|---|---|---|---|
| Badertsche 2023 | NR | 60.4/46.7 | 11.3/8.0 | NR | 8.5/8.0 | NR | 42.5/26.7 |
| Blockhaus 2023 | 1.5 ± 1.1/ 1.7 ± 1.4 | 65/40 | NR | 0/10 | 9/25 | 13/25 | NR |
| Cochet 2021 | NR | 22/NR | 6/NR | 11/NR | 6/NR | NR | 17/NR |
| Krisai 2022 | 3.0/1.9 | NR | NR | NR | NR | NR | NR |
| Kupusovic 2023 | 2.6 ± 1.2/ 2.4 ± 1.5 | 80/90.9 | 13.3/9.1 | 13.3/0 | 33.3/36.4 | 46.7/45.5 | 60/45.5 |
| Lemoine 2023 | 2.7 ± 1.7/ 2.3 ± 1.6 | 67/63 | 16/3 | 2/7.5 | 31/18 | 27/18 | NR |
| Monte 2023 | 1.8 ± 1.7/ 1.6 ± 1.2 | 43/42 | 13/8 | 5/11 | 10/11 | NR | NR |
| Musikantow 2022 | NR | 68/38 | 18/10 | 5/3 | 5/20 | NR | 43/25 |
| Maurhofer 2023 | NR | 65/62.5 | 7.5/10 | 5/5 | 20/17.5 | NR | NR |
| Meininghaus 2023 | NR | 80/97 | 5/21.2 | NR | NR | NR | NR |
| Reddy 2023 | 1.7 ± 1.2/ 1.6 ± 1.3 | 57/48 | 10.8/9.6 | 3.9/3.7 | 10.5/16.3 | 19.3/20.7 | 43.6/50.4 |
| Schipper 2023 | 3.0 ± 1.8/ 2.7 ± 1.7 | 72/69 | 17/17 | NR | 31/26 | NR | 35/33 |
| Tohoku 2023 | NR | 71/71 | 13/5 | 4/10 | 7/15 | 10/10 | NR |
| Urbanek 2023 | 2 ± 1.5/ 3 ± 2.2 | 66/71 | 14/16.5 | 5/7.5 | 14/13.5 | 13.5/11.5 | NR |
| Van de kar 2023 | NR | NR | 9.3/7.3 | NR | NR | NR | NR |
| Wahedi 2023 | 2.2 ± 1.5/ 2.4 ± 1.3 | 60/70 | 6/16 | 4/6 | 18/22 | 10/10 | NR |
| Chaumont 2024 | 1 ± 1.1/ 2 ± 0.7 | 38/41 | 9/7 | 3/7 | 6/4 | 5/2 | NR |
| Kueffer 2024 | 3 ± 1.5/ 3 ± 1.5 | 60.7/67.9 | 18.2/11.1 | 5.6/10.5 | 20.6/16.8 | NR | NR |
| Rattka 2024 | 3 ± 2.2/ 3 ± 2.2 | 78/55 | 17/32 | 7/4 | NR | NR | 63/68 |
| Rocca 2024 | 2 ± 1.5/ 2 ± 1.5 | 44.8/39.4 | 9.2/8.4 | 4.6/3.5 | 5.7/9.8 | 7.5/10.5 | NR |
| Reichlin 2025 | 2.0 ± 1.0/ 2.0 ± 1.0 | 53/55 | 12/9 | 4/7 | NR | 9/3 | NR |
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