High‐power, short‐duration atrial fibrillation ablation compared with a conventional approach: Outcomes and reconnection patterns

Abstract

Background: The effectiveness, safety, and pulmonary vein (PV) reconnection patterns of point-by-point high-power, short-duration (HPSD) ablation relative to conventional force-time integral (FTI)-guided strategies for atrial fibrillation (AF) ablation are unknown.Objectives: To compare 1-year freedom from atrial arrhythmia (AA), complication rates, procedural times, and PV reconnection patterns with HPSD AF AF ablation versus an FTI-guided low-power, long-duration (LPLD) strategy. Methods:We compared consecutive patients undergoing a first ablation procedure for paroxysmal or persistent AF. The HPSD protocol utilized a power of 50 W and durations of 6-8 s posteriorly and 8-10 s anteriorly. The LPLD protocol was FTI-guided with a power of ≤25 W posteriorly (FTI ≥ 300g•s) and ≤35 W anteriorly (FTI ≥ 400g•s).Results: In total, 214 patients were prospectively included (107 HPSD, 107 LPLD).Freedom from AA at 1 year was achieved in 79% in the HPSD group versus 73% in the LPLD group (p = .339; adjusted hazard ratio with HPSD, 0.67; 95% confidence interval, 0.36-1.23; p < .004 for non-inferiority). Procedure duration was shorter in the HPSD group (229 ± 60 vs. 309 ± 77 min; p < .005). Patients undergoing repeat ablation had a higher propensity for reconnection at the right PV carina in the HPSD group compared with the LPLD group (14/30 = 46.7% vs. 7/34 = 20.6%; p = .035).There were no differences in complication rates. Conclusion:HPSD AF ablation resulted in similar freedom from AAs at 1 year, shorter procedure times, and a similar safety profile when compared with an LPLD ablation strategy. Patients undergoing HPSD ablation required more applications at the right carina to achieve isolation, and had a significantly higher rate of right carinal reconnections at redo procedures.

Fast anatomical mapping of the carina and its implications for acute pulmonary vein isolation

“…Interestingly, utilization of high power‐short duration (HPSD) energy settings seems to be associated with a higher rate of remaining carina conduction. Klein et al 21 reported different reconnection patterns with HPSD (50 W) and force‐time integral guided low‐power long duration (LPDL, 25‐35 W) strategies. Although both groups showed similar freedom of arrhythmia at 1 year (79% vs 73%; P =.339), a higher propensity for reconnection at the right PV carina was found in the HPSD group compared with the LPLD group (46.7% vs 20.6%).…”

Acute and long‐term efficacy of ablation index‐guided higher power shorter duration ablation in patients with atrial fibrillation: A prospective registry

“…Several clinical studies have shown that high power, short duration ablation was safe, reduced total procedure time, and achieved comparable long‐term efficacy in AF recurrence 22‐25 . In recently published data, high power short duration ablation using 50 W/8‐10 seconds in anterior and 50 W/6‐8 seconds in posterior showed similar 1‐year AF‐free survival rate and shorter procedure times compared to conventional power FTI‐guided ablation in PVI 26 . This recent study did not apply real‐time AI or LSI estimation during ablation.…”

“…However, applying 50 W in 5 seconds showed variable FTI or lesion index (LSI) values according to CF: mean FTI varied from 47 to 376 g*seconds and mean LSI varied from 4.1 to 7.6 25 . Also, high power short duration ablation showed a higher propensity for reconnection of the right PV carina compared to conventional power ablation 26 …”

“… 22 , 23 , 24 , 25 In recently published data, high power short duration ablation using 50 W/8‐10 seconds in anterior and 50 W/6‐8 seconds in posterior showed similar 1‐year AF‐free survival rate and shorter procedure times compared to conventional power FTI‐guided ablation in PVI. 26 This recent study did not apply real‐time AI or LSI estimation during ablation. However, applying 50 W in 5 seconds showed variable FTI or lesion index (LSI) values according to CF: mean FTI varied from 47 to 376 g*seconds and mean LSI varied from 4.1 to 7.6.…”

“… 25 Also, high power short duration ablation showed a higher propensity for reconnection of the right PV carina compared to conventional power ablation. 26 …”