Pulsed field ablation for persistent atrial fibrillation: meta-analysis of pulmonary vein isolation with or without posterior wall isolation

Pulsed field ablation (PFA)-guided pulmonary vein isolation (PVI) has limited efficacy in treating persistent atrial fibrillation (AF) and requires additional substrate modification, but the efficacy of PVI combined with left atrial posterior wall isolation (PWI) under PFA remains controversial. This systematic review and meta-analysis aimed to compare the efficacy and safety of PFA-based PVI alone versus PVI + PWI in such patients. A systematic literature search was conducted up to March 11, 2026, with key endpoints of atrial tachyarrhythmia recurrence and procedural complications analyzed via a random-effects model. Thirteen studies (6 cohort, 7 single-arm) encompassing 1983 patients from diverse clinical centers were included. Cohort study analysis showed no significant recurrence reduction with PVI + PWI (RR = 1.10, 95%CI 0.78-1.57, P = 0.59, I² = 41%). PVI + PWI required more 3D electroanatomic mapping (RR = 1.47, P = 0.03, I² = 95%) and prolonged procedure time by 16.22 min (95%CI 0.35-32.08, P = 0.05, I² = 88%). Conclusion: PVI + PWI provides no significant efficacy benefit over PVI alone in PFA for persistent AF. It prolongs procedure duration and does not increase complication risk.