Comparative efficacy of high-power short duration and very-high power short-duration PVI: a post-hoc analysis of two randomized studies

Abstract Background, aims Pulmonary vein isolation (PVI) is the most effective means of maintaining sinus rhythm in atrial fibrillation (AF); point-by-point radiofrequency (RF) catheter ablation is a widely used approach to PVI. High power short duration (HPSD) and very high power short duration (vHPSD) e.g., 90W and 4 sec) are increasingly popular technologies, featuring higher power and shorter application durations compared to previous methods. In recent years multiple studies assessed the efficacy vHPSD PVI, all of which show similar arrhythmia recurrence rates to the HPSD technology. This, combined with an unprecedented reduction in procedural time, makes vHPSD a popular alternative to lower power modalities. Nevertheless, to date no randomized comparison exists between the HPSD and the vHPSD technology regarding arrhythmia recurrence. Aims, Methods In our study we aimed to analyze the data pooled from two single-center randomized trials comparing PVI performed with HPSD ablation using 50W power to vHPSD using 90W power: a) the HPSD-Remap study, conducted to assess PVI durability using mandated invasive remapping at three months after ablation, and b) the HPSD-Esophagus study, aimed at comparing esophageal safety of the two technologies using post-procedural endoscopy. Patients who underwent additional ablation at the three-month remap procedure and those lost to follow-up were excluded. Demographic and procedural data was obtained from the respective trial databases while recurrence data was collected during the regular clinical follow-up visits. Minimal follow-up time was one year. Recurrence was defined as either a) 12-lead ECG recording of atrial fibrillation, b) sustained atrial fibrillation episode registered using an implanted device, or c) the reporting of sustained symptoms which the patient identified as atrial fibrillation. Results Overall 90 (53%) patients from the vHPSD group and 79 (47%) patients from the HPSD group were analyzed. 107 (63%) patients had paroxysmal atrial fibrillation, mean left ventricular ejection fraction was 57%, and the mean age was 63 ±10 years. Ablation time was shorter in the vHPSD group (27±13 vs. 33±12 minutes, p=0.004) There was a trend towards shorter procedure time in the vHPSD group 65±22 minutes vs. 69±18 minutes, p=0.07. Left atrial dwell time was similar at 48±18 minutes (vHPSD) vs. 52±16 minutes (HPSD), p=0.18. The median follow-up time was 21 (14-30) months. Atrial fibrillation recurrence was observed in 15 (19%) vs. 22 (24%) for the HPSD and the vHPSD group, respectively. Cox regression revealed no significant difference between the two groups, HR: 1.43 (0.75 – 2.74) p=0.277. Conclusions Analyzing the pooled data from two randomized studies, we found no significant difference between atrial fibrillation recurrence following pulmonary vein isolation using HPSD (50W) and vHPSD (90W) technologies. Ablation time was significantly shorter in the vHPSD group, while the total procedure time was similar.