Voltage-Heat Duel: Pulsed Field Ablation vs. Very High-Power Short-Duration for Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) serves as a fundamental element in atrial fibrillation (AF) therapy. Pulsed field ablation (PFA) and very high-power short-duration radiofrequency ablation (vHPSD-RF) were recently introduced as novel ablation strategies. We conducted a comparative analysis of PFA and vHPSD-RF, with a specific focus on feasibility, safety profile and short-term effectiveness in our center.

Methods: Retrospective analysis of all patients (pts) with AF who underwent their index PVI in our center from 01.05.2022 to 30.06.2023 using PFA (FARAWAVE™, Boston Scientific, MA, USA) and vHPSD-RF (QDOT MICRO^TM, Biosense Webster, CA, USA). Procedural success was defined as isolation of all veins at the end of the procedure. Total procedure duration, left atrium (LA) dwell time, fluoroscopy time, dose area product (DAP), volume of used contrast media, length of hospital stay and major complications were compared between the two groups. Major complications were defined as death, stroke or transient ischemic attack (TIA), cardiac tamponade, atrial-esophageal fistula and vascular access complications requiring surgical intervention. All patients were regularly scheduled for follow-up visits 3-6 months after ablation. Between-group comparisons were performed using the Mann-Whitney U-test, Fisher's exact test and the log-rank test.

Results: A total of 82 pts were included, thereof 52 pts received PFA and 30 pts received vHPSD-RF. Only one patient experienced a major complication (stroke), which was probably not related to the procedure itself. Total procedure duration (64,19 ± 18,78 vs. 99,38 ± 32,31 minutes, p-value <0,001) and LA dwell time (41,20 ± 12,43 vs. 61,53 ± 28,57 minutes, p-value= 0,001) were significantly shorter in PFA, while vHPSD-RF was associated with substantially shorter fluoroscopy time and DAP (14,35 ± 5,76 vs. 9,27 ± 5,34 minutes, 14,21 ±9,36 vs. 10,58 ± 9,17 Gycm², p-values= <0,001 and 0,046 respectively) (Figure 1). No statistically significant differences were detected regarding the used volume of contrast media, length of hospital stay and AF recurrence rate in the first 6 months (Figure 2). Results are summarized in Table 1.

Conclusions: PFA and vHPSD-RF show favorable feasibility and safety profiles. While vHPSD-RF is associated with lower radiation exposure, PFA stands out for its short procedure times, even when employing high-density (HD) mapping.  Notably, both methods demonstrate comparable short-term effectiveness at the 6-month mark.

Table 1: summary of results