Comparison of room times between pulsed-field ablation and very high-power short-duration ablation

Abstract Background Pulsed-field ablation (PFA) has shown promise in improving atrial fibrillation (AF) ablation efficiency by reducing skin-to-skin procedure times while maintaining safety compared to advanced radiofrequency (RF) methods such as very high-power short-duration (vHPSD) ablation. While PFA requires deeper sedation (e.g., deep sedation or general anesthesia), its effect on the total time spent in the operating room (OR) is unknown. Purpose We aimed to compare the room time (i.e., the time between the patient entering and leaving the OR) and procedural subsections’ times of PFA and vHPSD procedures. Methods We enrolled consecutive patients who underwent PFA or vHPSD ablation at our center between November 2023 and July 2024. Room and procedural subsections’ times were analyzed and compared. Operators were divided into two subgroups by completed AF cases: experienced (300-1000 cases) and expert (>1000 cases) physicians. Furthermore, we performed a subanalysis after excluding PFA cases that included additional ablation beyond pulmonary vein isolation (PVI). Results We included 131 patients [66 (55-71) years, 86 (65.6%) had paroxysmal AF]. Eighty-seven (66%) patients underwent PFA, and 44 (34%) underwent vHPSD ablation. Twenty-four patients (27.6%) underwent additional ablation beyond PVI in the PFA group, while none had additional ablation with vHPSD. PFA outperformed vHPSD in terms of room time [71 (64-80) vs. 88 (75-99.8) mins, p<0.001]. Furthermore, almost all procedural phases were significantly shorter in PFA procedures compared to vHPSD (all p<0.001), except the "door-in to puncture" and the "puncture to transseptal" time (both p>0.05). Meanwhile, the "sheath-out to door-out" time was significantly longer in PFA cases (p<0.001). Expert operators’ room times were shorter than experienced ones’ with both energy sources. However, the difference was clinically less meaningful with PFA than with vHPSD [PFA: 69 (60.3-74) vs. 76 (66-87.3) mins, and 80 (72-87) vs. vHPSD: 97.5 (88.8-114.5) mins, respectively, both p<0.001]. The PVI-only subanalysis confirmed that time differences between PVI-only PFA and vHPSD align with those in the main population [PVI-only PFA room time: 72 (63-83) vs. vHPSD room time: 88 (75-99.8), p<0.001]. Expert operators’ room times were even shorter in the PFA PVI-only subpopulation than experienced ones’ [expert PFA PVI-only room time: 67 (60-76) vs. experienced PFA PVI-only room time: 76 (66-87.75) mins, p=0.013]. One major non-fatal complication occurred with PFA, while no major complication occurred with vHPSD. Conclusions PFA results in significantly shorter room time in AF ablation than vHPSD. The room time of PFA is less dependent on operator experience. PFA may enhance time efficiency in the EP lab even compared to the fastest RF technology.Graphical abstract