Cryoballoon versus Radiofrequency versus Pulsed Field Ablation for Persistent Atrial Fibrillation: A Meta Analysis

Abstract 2294785, presented at Western Atrial Fibrillation Symposium 2026

Ablation techniques for persistent AF include radiofrequency (RF), cryoballoon (CB) and the emerging pulsed‑field ablation (PFA). Prior studies show comparable efficacy between CB and RF, with CB offering shorter procedure times and a higher incidence of transient phrenic‑nerve palsy. The safety and efficacy of PFA relative to thermal techniques remain uncertain.We conducted a network meta‑analysis of randomized and observational studies comparing PFA, CB and RF ablation for persistent AF (search through August 2025). The primary outcome was freedom from atrial tachyarrhythmia (ATA) ≥6 months post‑procedure. Secondary outcomes included procedure time, fluoroscopy time, complications (tamponade, phrenic‑nerve palsy, esophageal injury) and repeat ablation rates.Twenty‑nine studies involving 5,400 patients (8 PFA, 13 CB, 12 RF) were included. Direct comparisons reproduced previous findings: CB and RF had similar ATA‑free survival (OR 1.00, 95% CI 0.85–1.18), but CB procedures were 45 minutes shorter on average and associated with more phrenic‑nerve palsy (OR 4.84). In the network analysis, PFA achieved ATA‑free survival comparable to CB and RF, with significantly lower fluoroscopy times and no reported phrenic‑nerve or esophageal injuries. Repeat ablation rates were lowest with PFA and highest with RF.CB and RF ablation yield similar efficacy for persistent AF, though CB offers shorter procedures at the cost of transient phrenic‑nerve palsy. PFA appears to combine procedural efficiency with improved safety, but randomized trials are needed for confirmation.