Clinical Outcomes of Pulsed Field Vs. Thermal Ablation for Paroxysmal Atrial Fibrillation: Systematic Review and Meta‐Analysis of Randomized Evidence

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ABSTRACT Aims Pulsed field ablation (PFA) is a non‐thermal alternative to conventional thermal ablation for paroxysmal atrial fibrillation (AF). We conducted an updated systematic review and meta‐analysis of randomized evidence comparing efficacy, safety, and procedural outcomes. Methods PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception through March 2026 for randomized controlled trials (RCTs) comparing PFA with thermal ablation in adults undergoing first catheter ablation for paroxysmal AF. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random‐effects models. Results Four RCTs enrolling 1 393 patients were included. PFA showed no statistically detectable difference in 12‐month treatment success (RR, 1.04; 95% CI, 0.97 to 1.12; I 2 = 7%), recurrent atrial arrhythmias (RR, 1.00; 95% CI, 0.77 to 1.29; I 2 = 42%), or composite serious adverse events (RR, 0.71; 95% CI, 0.32 to 1.57; I 2 = 7%). PFA shortened procedure time (MD, −22.42 min; 95% CI, −33.44 to −11.39; I 2 = 91%) and LA dwell time (MD, −25.73 min; 95% CI, −34.66 to −16.79; I 2 = 92%), but increased fluoroscopy time (MD, 7.34 min; 95% CI, 0.39 to 14.30; I 2 = 98%). Conclusions Across the included trial configurations, 12‐month efficacy estimates did not differ detectably. Sparse safety events and wide confidence intervals precluded equivalence claims. Pooled procedure and LA dwell times favored PFA, but platform, comparator, and workflow heterogeneity limit generalizability. Procedural findings are exploratory and should not be interpreted as direct energy‐specific effects.