Higher power short duration vs. lower power longer duration posterior wall ablation for atrial fibrillation and oesophageal injury outcomes: a prospective multi-centre randomized controlled study (Hi-Lo HEAT trial)

Abstract

Aims Radiofrequency (RF) ablation for pulmonary vein isolation (PVI) in atrial fibrillation (AF) is associated with the risk of oesophageal thermal injury (ETI). Higher power short duration (HPSD) ablation results in preferential local resistive heating over distal conductive heating. Although HPSD has become increasingly common, no randomized study has compared ETI risk with conventional lower power longer duration (LPLD) ablation. This study aims to compare HPSD vs. LPLD ablation on ETI risk. Methods and results Eighty-eight patients were randomized 1:1 to HPSD or LPLD posterior wall (PW) ablation. Posterior wall ablation was 40 W (HPSD group) or 25 W (LPLD group), with target AI (ablation index) 400/LSI (lesion size index) 4. Anterior wall ablation was 40–50 W, with a target AI 500–550/LSI 5–5.5. Endoscopy was performed on Day 1. The primary endpoint was ETI incidence. The mean age was 61 ± 9 years (31% females). The incidence of ETI (superficial ulcers n = 4) was 4.5%, with equal occurrence in HPSD and LPLD (P = 1.0). There was no difference in the median value of maximal oesophageal temperature (HPSD 38.6°C vs. LPLD 38.7°C, P = 0.43), or the median number of lesions per patient with temperature rise above 39°C (HPSD 1.5 vs. LPLD 2, P = 0.93). Radiofrequency ablation time (23.8 vs. 29.7 min, P < 0.01), PVI duration (46.5 vs. 59 min, P = 0.01), and procedure duration (133 vs. 150 min, P = 0.05) were reduced in HPSD. After a median follow-up of 12 months, AF recurrence was lower in HPSD (15.9% vs. LPLD 34.1%; hazard ratio 0.42, log-rank P = 0.04). Conclusion Higher power short duration ablation was associated with similarly low rates of ETI and shorter total/PVI RF ablation times when compared with LPLD ablation. Higher power short duration ablation is a safe and efficacious approach to PVI.

First clinical data on artificial intelligence‐guided catheter ablation in long‐standing persistent atrial fibrillation

“…A procedural duration of 182.00 ± 57.13 min is still considered long when compared to standard PVI duration in experienced centers using a HPSD ablation approach 18,19 . This is due to a longer mapping time when analyzing DISPERS areas as well as the subsequent additional ablation time.…”

“…[15][16][17] A procedural duration of 182.00 ± 57.13 min is still considered long when compared to standard PVI duration in experienced centers using a HPSD ablation approach. 18,19 This is due to a longer mapping time when analyzing DISPERS areas as well as the subsequent additional ablation time. However, a learning effect and a more routine system implementation is likely to reduce overall procedure duration significantly over time.…”

Myocardial injury and inflammation following pulsed‐field ablation and very high‐power short‐duration ablation for atrial fibrillation

“…Biophysical characteristics of HPSD determine an optimized lesion geometry adapted to the thickness of the posterior atrial wall by creating larger and shallower lesions as compared to standard RFA 5–7 . HPSD is associated with a similar safety profile and with equivalent to improved long‐term rhythm outcomes as standard RFA, while consistently reducing procedural duration 7–10 …”

“…[5][6][7] HPSD is associated with a similar safety profile and with equivalent to improved long-term rhythm outcomes as standard RFA, while consistently reducing procedural duration. [7][8][9][10] PFA is a novel, nonthermal cardiac ablation modality using highvoltage electric fields to create nanoscale pores in the cell membrane through a mechanism known as irreversible electroporation. 11,12 Cell membrane disruption compromises cell homeostasis eventually leading to cell death.…”

High power short duration versus low power long duration ablation in patients with atrial fibrillation: A meta‐analysis of randomized trials

“…9 HPSD has been demonstrated to produce larger, more superficial lesions that should not increase complication rate. 10,11 Nevertheless, trials showed conflicting results; specifically, Shin et al, 12 Power-AF 13 , and Pilot-AF 14 observed no significant differences between HPSD and low power long duration (LPLD) in contrast to the Short-AF 15 and Hi-Lo Heat 16 trials, regarding AF recurrences.…”