Pulsed Field Ablation vs. Cryoballoon Pulmonary Vein Isolation in Patients with Heart Failure and Reduced Ejection Fraction

Clin Res Cardiol (2025). DOI 10.1007/s00392-025-02737-x
A. Urbani (Frankfurt am Main)¹, L. Urbanek (Frankfurt am Main)¹, J. A. Kheir (Frankfurt am Main)¹, S. Bordignon (Frankfurt am Main)², M. Rocchetti (Frankfurt am Main)¹, D. Schaack (Frankfurt am Main)¹, S. Aminolsharieh Najafi (Frankfurt am Main)¹, A. Steyer (Frankfurt am Main)¹, M. A. Gunawardene (Frankfurt am Main)¹, A. Marx (Frankfurt am Main)¹, J. Lurz (Frankfurt am Main)¹, B. Schmidt (Frankfurt am Main)¹, K. R. J. Chun (Frankfurt am Main)^1
1Agaplesion Markus Krankenhaus Medizinische Klinik III - CCB Frankfurt am Main, Deutschland; ²Varisano Klinikum Frankfurt Höchst Elektrophysiologielabor Frankfurt am Main, Deutschland

Background
Catheter ablation is a cornerstone in the management of atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF). While thermal energy-based techniques such as cryoballoon ablation have been extensively studied, Pulsed Field Ablation (PFA) has recently emerged as a promising non-thermal alternative. Its performance in HFrEF patients, however, remains to be defined.

Objective
To compare clinical and procedural outcomes of PFA and cryoballoon ablation in HFrEF patients undergoing first-time pulmonary vein isolation (PVI).

Methods
We analyzed 93 consecutive HFrEF (LVEF ≤ 40%) patients who underwent PFA-based PVI between 2022 and 2025 and compared them with a historical cohort of HFrEF patients treated with cryoballoon PVI between 2012 and 2017 (Cryo1000 registry). The primary endpoint was recurrence of any atrial arrhythmia >30 seconds after a blanking period (BP) of 3 months. If a repeat procedure was performed during BP this was rated as an endpoint. Procedural metrics were also compared.

Results
A total of 25 PFA patients and 68 cryoballoon patients were included. Baseline characteristics were generally balanced, although the PFA group had a higher prevalence of male sex (79% vs 52%, p<0.05), persistent AF (70% vs 36%, p<0.01), and lower LVEF (31% vs 35%, p<0.05). 
Procedural time was significantly shorter in the PFA group (34 vs 65 min, p<0.001), as was fluoroscopy time (7.3  vs 9.7 min, p<0.01). There were no major complications in both group and only one complication at access site occured in the PFA group. The PFA group showed a lower recurrence rate of atrial arrhythmias at 1 year (47% vs 63%, p= 0,194).

Conclusion
Both technologies showed a good safety profile. PFA demonstrated shorter procedural and fluoroscopy times and furthermore a trend toward lower arrhythmia recurrence rates at 1 year. These findings support rhythm control with PVI as first line strategy in this vulnerable patient cohort and a  potential clinical benefit of PFA, which has to be confirmed in larger trials.