Reduced esophageal heating in high‐power short‐duration atrial fibrillation ablation in the contact force catheter era

Abstract

Background Atrial fibrillation (AF) ablation is alternative treatment to medical therapy. Most feared complication is atrioesophageal fistula Methods Observational, retrospective analysis of consecutive 355 patients undergoing first AF ablation. Low‐power long‐duration (LPLD) group contained 158 patients, with 121 (76.58%) having paroxysmal AF who underwent ablation with power 20/30W (anterior and posterior left atrial wall), 17 mL/min flow, and a contact force of 10–30 g for 30 s. High‐power short‐duration group (HPSD) contained 197 patients, with 113 (57.36%) having paroxysmal AF who underwent ablation at 45/50W of power with a contact force of 8–15 g/10–20 g and a 35 mL/min flow rate for 6–8 s on the anterior and the posterior left atrial wall, respectively. Both groups had pulmonary veins isolated and atrial flutter was ablated when needed. For patients not in sinus rhythm, cardioversion was performed before ablation Results There were no complications. LPLD group: Left atrial time 118.74 min, total 145.32 min, radiofrequency time 4317.99s, X‐ray 13.42 min, and elevation of luminal esophageal temperature (LET) in 132 (84.53%) patients. HPSD group: Left atrial time 72.16 min, total 93.76 min, radiofrequency time 1511.29s, X‐ray 7.6 min, and LET elevation in only 75 (38.07%) patients. A markedly higher rate of first‐pass isolation was observed in HPSD compared to LPLD, 77.16% versus 13.29%, respectively. Recurrence occurred in 64 (40.50%) and 32 (16.24%) in 28.45 and 22.35 months in LPLD and HPSD patients, respectively. In LPLD, 10 patients were submitted to endoscopy, and one (10%) had mild erythema and in HPSD, 13 performed the endoscopy, with two (15.38%) patients showing mild erythema Conclusion HPSD technique compared to the LPLD technique showed significant reduced radiofrequency and fluoroscopy times, higher rate of first‐pass isolation, lower recurrence rate, and esophageal temperature elevation and may also have a protective effect avoiding incidental esophageal injury due to these findings.

Comparison of Effectiveness and Safety between High-Power Short-Duration Ablation and Conventional Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis

“…In the HPSD RFA group, there were 9 studies [ 16 , 17 , 23 – 25 , 27 – 29 , 32 ] where ablation was performed with a setting of 50 W, while 7 studies [ 18 , 19 , 21 , 22 , 26 , 30 , 31 ] with a power setting of 40–50 W. To reduce heterogeneity, two studies [ 20 , 32 ] exceeding the power of 50 W were excluded. Without increased complication rates, freedom from atrial arrhythmia at one year was higher in the HPSD RFA group with the power setting of 40–50 W ( P =0.03), conversely, no difference was found in this endpoint between the two groups with the power setting of 50 W ( P =0.52) (Supplementary Materials, Figure S3 ).…”

“…)e flowchart of the detailed search progress is illustrated in Figure 1. After removing the duplicated articles and browsing the abstracts, titles, or full texts, consequently, seventeen studies [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] with 4934 patients were enrolled in this meta-analysis. Among these studies, ten [16, 18-21, 23, 24, 27-29] were retrospective cohort studies and seven [17,22,25,26,[30][31][32] were prospective studies in which only one study [30] was a randomized controlled trial (RCT).…”

“…Sensitivity analysis demonstrated the robustness of the above results during the sequential exclusion of studies except for first-pass isolation, freedom from atrial arrhythmia, and acute PVR. Low heterogeneity following exclusion of two studies 3) 1 (all with esophageal lesions) * [28,31] based on freedom from atrial arrhythmia (I 2 � 2%) and one study [32] based on acute PVR (I 2 � 0). Despite reduced heterogeneity, there were no changes in the results of differences between two the groups.…”

Atrioesophageal Fistula After Atrial Fibrillation Ablation: A Case Report

“… 3 Additional publications, however, have reported a decreased temperature elevation of the esophagus and less esophageal injury, which may be protective against AEF formation if a high-power short-duration approach is used rather than a low-power long-duration ablation technique. 4 …”

“…Higher catheter energy but a shorter duration has also been shown to be more protective than a longer duration with lower catheter energy. 4 …”