Abstract Body (Do not enter title and authors here): Background
Pulsed field ablation (PFA) has become a cornerstone for atrial fibrillation ablation. Multiple platforms have been developed and approved worldwide, and routine screening for asymptomatic brain injury (ABI) has been included in several trials as part of the safety assessment of this technology. The incidence by catheter/platform, predictors of occurrence, and clinical impact remain incompletely understood.

Research Question
In patients with atrial fibrillation undergoing pulmonary vein isolation, does the incidence of ABI vary between different PFA platforms?

Methods
We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies reporting on patients who underwent PFA and post-procedure brain MRI to screen for ABI. The review was conducted in accordance with PRISMA guidelines. A random-effects proportion meta-analysis was performed, with subgroup analysis based on the PFA platform used. For studies including a thermal ablation control group, risk ratio (RR) was used to compare outcomes. Finally, a meta-regression was conducted to identify potential predictors of ABI incidence.

Results
A total of 19 studies reporting data from 742 patients who underwent post-ablation brain MRI were included in this review. The pooled incidence of silent cerebral events (new findings visible only on DWI sequences) and silent cerebral lesions (new findings on both DWI and FLAIR sequences) was 5% each (95% CI, 3%–8%). The pooled incidence of any ABI was 10% (95% CI, 8%–13%). A platform-level subgroup analysis demonstrated comparable outcomes across the platforms with available data (Figure 1). The meta-regression included age, sex, CHA2DS2-VASc score, and incidence of symptomatic stroke/TIA, but no statistically significant associations were identified. In the four studies that included a thermal ablation control group, there was no significant difference in ABI incidence between PFA and thermal ablation (RR: 1.37; 95% CI, 0.68–2.74; P = 0.38; I2 = 16%) (Figure 2). Seven studies reported follow-up MRI in patients who presented with an ABI. Among 20 patients with ABI after ablation, radiologic lesions persisted in 2 patients.

Conclusion
ABI is a relatively frequent finding following PFA; however, current evidence does not reveal significant differences between available platforms. Radiologic findings tend to be transient, suggesting a limited long-term clinical impact.