Hemolysis and Renal Safety of Pulsed-Field Versus Thermal Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis

Kılıç M. E., Arayıcı M. E., Yılancıoğlu R. Y., Turan O. E., Özcan E. E.

HEART RHYTHM, cilt.24, ss.1-10, 2026 (SCI-Expanded, Scopus)

  • Yayın Türü: Makale / Tam Makale
  • Cilt numarası: 24
  • Basım Tarihi: 2026
  • Doi Numarası: 10.1016/j.hrthm.2026.01.026
  • Dergi Adı: HEART RHYTHM
  • Derginin Tarandığı İndeksler: Scopus, Science Citation Index Expanded (SCI-EXPANDED), CINAHL, EMBASE, MEDLINE
  • Sayfa Sayıları: ss.1-10
  • Dokuz Eylül Üniversitesi Adresli: Evet

Özet

Background

Pulsed-field ablation (PFA) is a non-thermal modality for atrial fibrillation (AF) ablation; concerns persist regarding intravascular hemolysis and acute kidney injury (AKI).

Objective

To compare biomarker-defined hemolysis and clinical AKI after PFA versus thermal ablation.

Methods

PRISMA-adherent systematic review and random-effects meta-analysis of comparative observational studies in adults undergoing AF ablation. Major databases and trial registries were searched. Risk of bias was assessed with ROBINS-I. Co-primary outcomes were change-from-baseline hemolysis biomarkers (lactate dehydrogenase [LDH], haptoglobin, bilirubin) and AKI incidence (preferentially KDIGO-defined).

Results

Twelve studies (n=5,158; AKI analysis n=4,884; 2,122 PFA, 2,762 thermal) met criteria. Versus thermal ablation, PFA produced significantly greater hemolysis: LDH mean difference (MD) +63.79 U/L (p<0.001); haptoglobin MD −0.30 g/L (p=0.036); bilirubin MD +1.91 μmol/L (p=0.023). AKI risk did not differ (risk ratio [RR] 1.14, 95% CI 0.42–3.12; p=0.80; absolute rates 3.5% vs 3.1%). PFA was associated with significantly lower major bleeding (RR 0.15, 95% CI 0.04–0.62; p=0.009) and shorter procedure time (MD −25.81 min, 95% CI −49.26 to −2.36; p=0.031). Hemolysis magnitude varied by PFA platform; AKI did not. Limitations include observational designs and heterogeneity.

Conclusion

PFA increases biomarker-defined intravascular hemolysis relative to thermal ablation without increasing population-level AKI. Coupled with reduced major bleeding and enhanced procedural efficiency, these data support PFA use; dose discipline, hydration, and platform selection remain important for high-risk patients.

Background

Pulsed-field ablation (PFA) is a non-thermal modality for atrial fibrillation (AF) ablation; concerns persist regarding intravascular hemolysis and acute kidney injury (AKI).

Objective

To compare biomarker-defined hemolysis and clinical AKI after PFA versus thermal ablation.

Methods

PRISMA-adherent systematic review and random-effects meta-analysis of comparative observational studies in adults undergoing AF ablation. Major databases and trial registries were searched. Risk of bias was assessed with ROBINS-I. Co-primary outcomes were change-from-baseline hemolysis biomarkers (lactate dehydrogenase [LDH], haptoglobin, bilirubin) and AKI incidence (preferentially KDIGO-defined).

Results

Twelve studies (n=5,158; AKI analysis n=4,884; 2,122 PFA, 2,762 thermal) met criteria. Versus thermal ablation, PFA produced significantly greater hemolysis: LDH mean difference (MD) +63.79 U/L (p<0.001); haptoglobin MD −0.30 g/L (p=0.036); bilirubin MD +1.91 μmol/L (p=0.023). AKI risk did not differ (risk ratio [RR] 1.14, 95% CI 0.42–3.12; p=0.80; absolute rates 3.5% vs 3.1%). PFA was associated with significantly lower major bleeding (RR 0.15, 95% CI 0.04–0.62; p=0.009) and shorter procedure time (MD −25.81 min, 95% CI −49.26 to −2.36; p=0.031). Hemolysis magnitude varied by PFA platform; AKI did not. Limitations include observational designs and heterogeneity.

Conclusion

PFA increases biomarker-defined intravascular hemolysis relative to thermal ablation without increasing population-level AKI. Coupled with reduced major bleeding and enhanced procedural efficiency, these data support PFA use; dose discipline, hydration, and platform selection remain important for high-risk patients.