Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation

The ADVENT trial was a multicenter, randomized, single-blind, noninferiority study comparing pulsed field ablation (PFA) with thermal ablation (radiofrequency or cryoballoon) in 607 patients (≤75 years) with drug-refractory paroxysmal atrial fibrillation. At 1 year, freedom from a composite endpoint (procedural failure, arrhythmia recurrence, antiarrhythmic drug use, cardioversion, or repeat ablation) was 73.3% for PFA and 71.3% for thermal ablation (between-group difference: 2.0 percentage points; 95% Bayesian credible interval: -5.2 to 9.2; posterior probability of noninferiority: >0.999). Serious adverse events occurred in 2.1% vs. 1.5%, respectively (difference: 0.6 percentage points; posterior probability of noninferiority: >0.999). PFA showed less pulmonary vein narrowing (−0.9% vs. −12.0%), shorter procedure time (∼106 min vs. ∼123 min), and lower stent thrombosis. MRI-detected silent cerebral lesions occurred in 9% (PFA) vs. 0% (thermal). Despite superior imaging metrics and procedural benefits, clinical efficacy remained comparable. The trial supports PFA as a viable and potentially safer alternative to thermal ablation with implications for procedural optimization and long-term strategy refinement.

The ADVENT trial was a multicenter, randomized, single-blind, noninferiority study comparing pulsed field ablation (PFA) with thermal ablation (radiofrequency or cryoballoon) in 607 patients (≤75 years) with drug-refractory paroxysmal atrial fibrillation. At 1 year, freedom from a composite endpoint (procedural failure, arrhythmia recurrence, antiarrhythmic drug use, cardioversion, or repeat ablation) was 73.3% for PFA and 71.3% for thermal ablation (between-group difference: 2.0 percentage points; 95% Bayesian credible interval: -5.2 to 9.2; posterior probability of noninferiority: >0.999). Serious adverse events occurred in 2.1% vs. 1.5%, respectively (difference: 0.6 percentage points; posterior probability of noninferiority: >0.999). PFA showed less pulmonary vein narrowing (−0.9% vs. −12.0%), shorter procedure time (∼106 min vs. ∼123 min), and lower stent thrombosis. MRI-detected silent cerebral lesions occurred in 9% (PFA) vs. 0% (thermal). Despite superior imaging metrics and procedural benefits, clinical efficacy remained comparable. The trial supports PFA as a viable and potentially safer alternative to thermal ablation with implications for procedural optimization and long-term strategy refinement.