Enhancing efficiency in pulmonary vein isolation: hybrid high-power strategy with consistent long-term recurrence rates

Abstract Introduction Recent studies comparing very high-power short-duration (vHP-SD) ablation with traditional high-power (50W) ablation index (AI) protocols in pulmonary vein isolation (PVI) show vHP-SD to be effective and safe, with high rates of first-pass isolation. However, limitations exist on the anterior left atrial wall, where thicker areas may benefit from alternative approaches. Objective We propose a Hybrid Strategy combining vHP-SD ablation (90W) on the posterior atrial wall and AI-guided ablation (50W, 450f) on other regions, aiming to improve efficacy, efficiency, and safety, and reduce recurrence rates at 12 months. Methods We enrolled 120 consecutive patients (83 with paroxysmal and 37 with persistent atrial fibrillation) undergoing their first PVI (60 patients per strategy group), comparing outcomes of the hybrid strategy with those of standard AI-guided ablation. Periprocedural data, including RF and procedural time, were collected, and recurrence rates - defined as any atrial arrhythmia episode lasting over one hour - were evaluated at 12 months. Inter-lesion spacing was 5-6 mm in all cases (Figure 1). Results RF time was significantly reduced in the Hybrid group (490±158 s) compared to the AI group (987±204 s, P<0.0001), and procedure duration was shorter for the Hybrid group (68±17 min) than for the AI group (75±22 min, P=0.03), especially in patients with persistent AF (Figure 2). The Hybrid group also experienced reduced radiation exposure (154±87 s vs. 120±85 s, P=0.002). While acute outcomes were comparable, the Hybrid strategy showed slightly lower recurrence rates overall (28% vs. 30%) and in patients with persistent AF (15% vs. 35.3%), although these differences were not statistically significant. One complication (pseudoaneurysm requiring compression) occurred in the AI group, and one case of diaphragmatic paralysis was reported in the Hybrid group during follow-up. Conclusion The hybrid PVI strategy combining vHP-SD and AI protocols is safe and efficient, achieving low procedure times, reduced ablation and radiation exposure, and a high rate of first-pass isolation, with recurrence rates comparable to AI-alone ablation at 12 months.A) AI Procedure. B) Hybrid Procedure Hybrid Vs AI-Alone Periprocedural and FU