Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: results of a single center, real-world experience

Abstract Background Catheter ablation (CA) is a key treatment for atrial fibrillation (AF), with international guidelines now endorsing class I indications for its use in various clinical contexts. Pulsed field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency ablation are recent technologies for AF treatment. However, the procedural performance, safety, and acute effectiveness of PFA compared to vHPSD are not yet well established. Objective This study aimed to compare PFA with vHPSD for the management of paroxysmal and persistent AF. Methods We conducted an observational, single-center study enrolling 90 consecutive patients (mean age 61.9 ± 9.9; 23.3% female) with paroxysmal (n=74) or persistent (n=16) AF. Patients were treated with either a bidirectional, variable loop size (25–35 mm) ablation and mapping PFA catheter (n=45; persistent AF n=8) or a vHPSD catheter with microelectrodes and 6 thermocouples for real-time temperature monitoring during ablation (90 W, 4 seconds; n=45; persistent AF n=8) between 2020 and 2024. Pulmonary vein isolation (PVI) was the primary efficacy endpoint. The primary safety endpoint was a composite of procedure-related complications. Results Demographic characteristics were similar between the two groups (Table 1). Successful PVI was achieved in all patients, with shorter procedure durations in the PFA group (68.8 ± 17.9 minutes) compared to vHPSD (113.6 ± 30.6 minutes; p = 0.00054). This difference remained significant after propensity score matching (n=42; PFA, 70 ± 18.1 minutes; vHPSD, 112.8 ± 31.5 minutes; p = 0.000577) and when stratifying by several subgroups, including isolated PVI, PVI plus cavo-tricuspid isthmus (CTI) ablation, paroxysmal AF, persistent AF, and posterior wall ablation (Table 2). Fluoroscopy time was shorter for PFA but not significantly different (PFA, 10.25 ± 5.7 minutes; vHPSD, 11 ± 6.45 minutes; p = 0.56). PFA was associated with more frequent use of general anesthesia (p < 0.0001). Primary safety outcome events occurred in 1 patient (1.1%), with low rates in both groups (PFA, 0%; vHPSD, 2.2%). Conclusion In this single-center experience, PFA was associated with more frequent use of general anesthesia, shorter procedural times, and similar fluoroscopy exposure compared to vHPSD ablation, with both techniques exhibiting comparable safety and acute efficacy.Table 1:Demographic Characteristics Table 2:Procedural Details