Radiofrequency ablation of atrial fibrillation—50 W or 90 W?

Abstract

Background: This study sought to evaluate the short and midterm efficacy and safety of the novel very high power very short duration (vHPvSD) 90 W approach compared to HPSD 50 W for atrial fibrillation (AF) ablation as well as reconnection patterns of 90 W ablations. Methods and Results: Consecutive patients undergoing first AF ablation with vHPvSD (90 W; predefined ablation time of 3 s for posterior wall ablation and 4 s for anterior wall ablation) were compared to patients using HPSD (50 W; ablation index-guided; AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) retrospectively. A total of 84 patients (67.1 ± 9.8 years; 58% male; 47% paroxysmal AF) were included (42 with 90 W, 42 with 50 W) out of a propensity score-matched cohort. 90 W ablations revealed shorter ablation times (10.5 ± 6.7 min vs. 17.4 ± 9.9 min; p = .001). No major complication occurred. 90 W ablations revealed lower first pass PVI rates (40% vs. 62%; p = .049) and higher AF recurrences during blanking period (38% vs. 12%; p = .007). After 12 months, both ablation approaches revealed comparable midterm outcomes (62% vs. 70%; log-rank p = .452). In a multivariable Cox regression model, persistent AF (hazard ratio [HR]: 1.442, 95% confidence interval [CI]: 1.035-2.010, p = .031) and increased procedural duration (HR: 1.011, 95% CI: 1.005-1.017, p = .001) were identified as independent predictors of AF recurrence during follow-up.Conclusions: AF ablation using 90 W vHPvSD reveals a similar safety profile compared to 50 W ablation with shorter ablation times. However, vHPvSD ablation was associated with lower rates of first-pass isolations and increased AF recurrences during the blanking period. After 12 months, 90 W revealed comparable efficacy results to 50 W ablations in a nonrandomized, propensity-matched comparison.

Clinical outcomes with very high power very short duration ablation for atrial fibrillation: The jury is still out

“…It is important to note that whilst these parameters are excellent acute markers for clinical efficacy, they are not a substitute for clinical outcome data on follow up. In this edition of the Journal of Cardiovascular Electrophysiology , Mueller and colleagues present the results of a single center, retrospective, propensity matched study comparing 12‐month outcomes of ablation with 90 W (vHPvSD) versus Ablation Index (AI) guided 50 W (sRF) in 84 patients 4 . They found that 90 W vHPvSD ablation was associated with shorter ablation times (10.5 vs. 17.4 min; p = .001), but with lower FPI rates (40% vs. 62%; p = .049), higher AF recurrence during the blanking period (38% vs. 12%; p = .007), and a trend towards a lower freedom from AF at 12 months (62% vs. 75%; p = .071).…”

“…versus Ablation Index (AI) guided 50 W (sRF) in 84 patients. 4 They found that 90 W vHPvSD ablation was associated with shorter ablation times (10.5 vs. 17.4 min; p = .001), but with lower FPI rates (40% vs. 62%; p = .049), higher AF recurrence during the blanking period (38% vs. 12%; p = .007), and a trend towards a lower freedom from AF at 12 months (62% vs. 75%; p = .071).…”

Primer on Machine Learning in Electrophysiology

“…In cardiac EP, there have been several studies using least squares regression to predict different outcomes, ranging from predicting the likelihood of AF recurrence to what wattage catheter ablations perform better. [9][10][11][12][13][14][15] Least squares regressions have been preferred in these studies because they are easy to implement, can learn the key features (from EHR data/clinical covariates or ECG biomarkers, or in performing survival analysis), and are interpretable. Least squares regressions are often included with other ML algorithms to help find the best performing model.…”

Long-Term Durability of High- and Very High-Power Short-Duration PVI by Invasive Remapping: The HPSD Remap Study

“…[5][6][7][8][9] Recently, a very HPSD (vHPSD; 90 W, 4 s) technique has been introduced, but initial efficacy results were mostly discouraging regarding first-pass isolation rates, acute reconnection rates, and arrhythmia-free survival. [10][11][12][13][14] We hypothesized that vHPSD PVI could result in similar acute and long-term efficacy as ablation indexguided PVI with 50 W. 11 Therefore, we designed the HPSD Remap study (Efficacy Comparison of High and Very High Power Short Duration Pulmonary Vein Isolation, URL: https://www.clinicaltrials.gov; unique identifier NCT05459831), in which durability of lesions was assessed by a repeat electrophysiology study after an index PVI performed with either a 90-or 50-W power setting.…”

“…5–9 Recently, a very HPSD (vHPSD; 90 W, 4 s) technique has been introduced, but initial efficacy results were mostly discouraging regarding first-pass isolation rates, acute reconnection rates, and arrhythmia-free survival. 10–14…”