Contemporary Catheter Ablation for Paroxysmal Atrial Fibrillation: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Background: The relative efficacy and safety of radiofrequency ablation (RFA), cryoballoon ablation (CBA), and pulsed field ablation (PFA) for paroxysmal atrial fibrillation (PAF) remain unclear. This research seeks to assess and contrast these catheter ablation techniques. Methods: A systematic search identified randomized controlled trials (RCTs) that compared at least two of these techniques for PAF. The primary efficacy outcome was the absence of atrial arrhythmia recurrence post-ablation after the blanking period, The safety outcome involved any procedure-related complication. The secondary outcomes included procedure and fluoroscopy times. Frequentist random-effects network meta-analyses were conducted using odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). Results: Eighteen RCTs involving 3,219 PAF patients were included. RFA, CBA, and PFA showed no significant difference in rates of freedom from atrial arrhythmia recurrence (CBA vs. RFA: OR = 1.03, 95% CI: 0.87 to 1.22; PFA vs. RFA: 1.13, 0.80 to 1.61; PFA vs. CBA: 1.09, 0.77 to 1.56) and procedure-related complications (CBA vs. RFA: OR = 1.31, 95% CI: 0.82 to 2.08; PFA vs. RFA: 1.12, 0.34 to 3.64; PFA vs. CBA: 0.86, 0.26 to 2.84). PFA and CBA were associated with shorter procedure times than RFA (MD = -31.18, 95% CI: -49.74 to -12.61; MD = -24.77, 95% CI: -32.82 to -16.71, respectively), with no significant difference between PFA and CBA. Fluoroscopy times were similar across techniques. Conclusion: PFA, CBA, and RFA demonstrated comparable efficacy and safety for PAF treatment, but PFA and CBA offered shorter procedure times than RFA.