Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF)^[1]. PVI has been shown to be superior to antiarrhythmic drug therapy in preventing the recurrence of atrial arrhythmias, while also improving symptoms, exercise capacity, and quality of life^[2]. The conventional approach involves manual manipulation of an ablation catheter to deliver point-by-point thermal energy at the pulmonary vein (PV) antrum, thereby achieving electrical isolation. Over time, alternative techniques, including robotic magnetic navigation (RMN) and cryoballoon (CRYO) ablation, have been introduced. However, challenges such as AF recurrence, non-selective injury to adjacent structures (e.g., the esophagus and phrenic nerve), and procedure-related complications remain unavoidable in clinical practice^[3]. Consequently, the pursuit of more efficient and safer ablation technologies remains an active area of research.

In this context, Pulsed field ablation (PFA) continues to evolve. Beyond conventional continuous energy delivery, emerging evidence suggests that pulsed delivery of radiofrequency energy may offer distinct advantages. The application of pulsed energy modulation has been proposed as a strategy to achieve more controlled and predictable lesion formation, potentially reducing the risk of collateral thermal injury while maintaining ablation efficacy^[4]. Collectively, these findings suggest that pulsed radiofrequency energy delivery may represent a promising avenue for improving the safety and precision of thermal ablation.

In recent years, pulsed field ablation (PFA) has emerged as a promising alternative to conventional ablation modalities for PVI^[5]. PFA delivers ultrashort, high-amplitude electrical pulses to achieve non-thermal tissue ablation. Its mechanism of action, termed irreversible electroporation, induces cardiomyocyte death through the formation of permanent nanopores in the cell membrane, resulting in irreversible cellular injury independent of thermal effects (heating or freezing). The safety and efficacy of PFA have been demonstrated in several clinical trials^[6-11]. Notably, the ADVANCE trial recently showed that PFA was non-inferior to RFA and CRYO ablation with respect to serious adverse events, while achieving comparable rates of acute procedural success^[12]. Despite these encouraging results, the comparative performance of PFA versus established ablation strategies remains incompletely defined. In this study, we compare PFA with RMN and CRYO ablation with respect to procedural parameters and perioperative complications.

PFA, CRYO ablation, and RMN ablation are emerging catheter-based strategies developed from conventional RFA for the treatment of AF. To our knowledge, no previous study has directly compared these three modalities within the same analysis. In this comparative study, we found that: (1) PFA was associated with shorter LA procedural time and lower radiation exposure than conventional thermal ablation approaches, suggesting greater procedural efficiency; (2) the acute procedural success of PVI was similarly high across all three groups, supporting the efficacy of PFA; and (3) the overall incidence of complications was comparable among treatment strategies, although PFA was associated with fewer procedure-specific complications, indicating a favorable safety profile.

Regarding procedural efficiency, previous studies have shown that PFA significantly shortens both total procedure time and LA procedural time compared with conventional RFA^[9,15,16]. Although RMN ablation has generally been reported to require longer procedure times than manual RFA^[17,18], direct comparisons between PFA and RMN have been lacking. Our findings help address this gap, demonstrating that RMN was associated with the longest total procedure time, consistent with procedural expectations. Comparison between PFA and CRYO ablation appears more complex. While some studies have reported shorter procedure times with PFA, others have found no significant difference, which may reflect variations in procedural definitions and the use of three-dimensional electroanatomical mapping^[19,20]. To better characterize these differences, we performed a detailed analysis of individual procedural stages. Although PFA required general anesthesia and post-anesthesia recovery, which contributed to a longer total procedural time, it was associated with the shortest LA procedural time, consistent with previous reports^[12]. Analysis of the LA procedural phase further highlighted differences among techniques. RMN required point-by-point lesion delivery and was therefore the most time-consuming. Similarly, CRYO required optimization of PV occlusion before each application, followed by a freezing cycle of 180-240 s and a subsequent thawing period, all of which contributed substantially to procedural duration. In contrast, PFA required less stringent tissue contact and involved ultrashort energy delivery, resulting in the shortest LA operation time and the lowest proportion of overall procedure time dedicated to this phase.

In terms of procedural efficacy, previous studies have demonstrated that PFA is non-inferior to both RFA and CRYO ablation with respect to acute procedural success, freedom from atrial tachyarrhythmia after the 3-month blanking period, and the incidence of serious adverse events within 1 year^[5,21]. More notably, the unique properties of pulsed-field energy have been associated with higher rates of first-pass PVI compared with conventional thermal ablation strategies^[22,23]. Our findings are consistent with these observations. In the PFA group, all targeted PVs in 50 patients were successfully isolated with the initial application set, without the need for supplemental ablation. In contrast, additional “touch-up” ablation or repeat freezing was more frequently required in the RMN and CRYO groups. This procedural efficiency likely reflects the mechanism of field-based ablation, which is less dependent on precise catheter-tissue contact for effective lesion formation. A limitation of the present study is the absence of long-term follow-up data at our center. Ongoing follow-up will evaluate long-term rhythm outcomes after ablation, and planned subgroup analyses will further explore potential associations between PFA efficacy and baseline patient characteristics.

Regarding radiation exposure, the available literature remains inconsistent. Some studies have reported longer fluoroscopy time and higher radiation exposure with PFA than with RFA^[15,24], whereas comparisons between PFA and CRYO ablation have yielded variable results^[8,12,25]. The SINGLE SHOT CHAMPION study suggested that PFA may reduce radiation exposure, with further reductions potentially achievable through integration with three-dimensional electroanatomical mapping systems^[5]. Our phase-based analysis provides additional insight into these differences. During the preprocedural preparation phase, fluoroscopy time and radiation dose were broadly similar across all three groups. However, marked differences became apparent during LA manipulation. As anticipated, RMN ablation was associated with the lowest fluoroscopy time and radiation dose, reflecting its dependence on three-dimensional mapping and remote robotic catheter navigation^[14]. PFA and CRYO demonstrated comparable fluoroscopy times during the LA phase, likely owing to similar requirements for real-time imaging guidance. Repeated adjustment of catheter orientation during PFA is procedurally analogous to repositioning the CRYO to achieve optimal PV occlusion under fluoroscopy. However, radiation dose was significantly lower in the PFA group than in the CRYO group. This difference likely reflects the greater reliance on repeated contrast injections during CRYO ablation for pulmonary venography and confirmation of complete vein occlusion.

In terms of safety, PFA may offer distinct advantages in reducing certain procedure-specific complications. The tissue selectivity of irreversible electroporation has the potential to limit energy-related injury to adjacent extracardiac structures, particularly atrio-esophageal injury and phrenic nerve palsy^[26,27], both of which may result in severe or even life-threatening consequences. Meta-analyses have further supported the potential advantages of PFA with respect to procedural efficiency and lower risks of phrenic nerve and esophageal injury compared with conventional thermal ablation strategies^[23-25]. In the present study, the overall incidence of complications was comparable among the PFA, RMN and CRYO groups. The absence of statistically significant differences may reflect the limited sample size and low event rates. Importantly, complications inherent to LA ablation procedures, including pericardial tamponade and stroke, remain relevant with PFA^[20]. PFA may also be associated with procedure-specific risks, most notably intravascular hemolysis, which in severe cases can contribute to acute kidney injury^[28]. However, previous studies have suggested that clinically significant anemia or renal impairment is uncommon^[29]. Consistent with current evidence, renal function was carefully assessed preoperatively in all patients, and adequate perioperative hydration was routinely provided. None of the 50 patients treated with PFA in this cohort developed symptomatic hemolysis or renal impairment, suggesting that this perioperative management approach was effective in our clinical setting^[30].

Regarding perioperative recovery, although PFA requires general anesthesia and larger-diameter sheath, our findings indicate that postoperative recovery was comparable to that observed after RMN and CRYO ablation. General anesthesia has been widely adopted internationally across different catheter ablation strategies^[31], and the cumulative experience from high-volume centers provides practical reassurance regarding its perioperative feasibility and safety. The larger sheath used for PFA may theoretically contribute to greater access-site discomfort and increase the need for hemostasis following suture removal. However, in our cohort these factors did not appear to influence postoperative recovery or decisions regarding hospital discharge under routine standardized care. Emerging international evidence further suggests that same-day discharge after PFA may be feasible. The non-thermal mechanism of electroporation reduces collateral tissue injury and may lower the incidence of procedure-related complications, thereby supporting more favorable early recovery and facilitating earlier discharge^[32]. Nevertheless, implementation of an accelerated discharge pathway remains challenging in the current Chinese clinical setting. This is likely influenced not only by institutional workflow considerations but also by patient acceptance and expectations regarding postoperative observation.