Abstract Body (Do not enter title and authors here):
Background:
Pulsed field ablation (PFA) is an emerging energy source in catheter ablation for atrial fibrillation (AF), offering tissue selectivity and procedural efficiency. While pulmonary vein isolation (PVI) remains the cornerstone of ablation, adjunctive posterior wall isolation (PWI) is increasingly considered, particularly in persistent atrial fibrillation (AF). However, the comparative benefits and risks of PVI + PWI versus PVI alone using PFA remain unclear. This meta-analysis aimed to evaluate the clinical efficacy and safety outcomes of PVI + PWI compared to PVI alone in patients with persistent AF undergoing PFA.

Methods:
A comprehensive literature search was conducted using PubMed, Embase, and Google Scholar databases. Random-effects models were used to calculate Mantel-Haenszel odds ratios (ORs) with 95% confidence intervals (CIs). The inverse variance method with DerSimonian–Laird (DL) of Tau2 was used to calculate mean differences (MDs) with CIs. Statistical significance was set at p < 0.05. The primary endpoint was the recurrence of atrial fibrillation or atrial tachycardias (AF/AT) over the average follow-up of one year after the procedure. Secondary outcomes included in-hospital complications, mean procedure time, and mean fluoroscopy time.

Results:
Five studies, including 1,046 patients with persistent atrial fibrillation (AF), were included. There was no statistically significant difference in the recurrence of atrial fibrillation or atrial tachycardia (AF/AT) between patients who underwent PVI alone and those who received additional PWI along with PVI using pulsed field ablation (OR: 0.83; 95% CI: 0.40–1.73, P = 0.62). In-hospital complication rates were higher but not statistically significant with PVI + PWI (OR: 1.74; 95% CI: 0.92–3.30; p = 0.09). The PVI + PWI group had significantly longer mean procedure time (MD: 17.48 minutes; 95% CI: 0.79–34.17; p < 0.05) and fluoroscopy time (MD: 1.99 minutes; 95% CI: 0.02–3.96; p = 0.05).

Conclusion:
In patients with persistent atrial fibrillation, PVI + PWI using pulsed field ablation did not significantly reduce arrhythmia recurrence compared to PVI alone but was associated with increased procedural and fluoroscopy times and a trend toward higher in-hospital complications. Further large-scale randomized studies are warranted to validate these findings.

Keywords: Persistent atrial fibrillation; Catheter ablation; Pulmonary vein isolation; Posterior wall isolation; Pulsed field ablation.