Optimized workflow with hybrid (very) high-power short-duration radiofrequency ablation renders point-by-point pulmonary vein isolation as fast and effective as cryoballoon ablation

A hybrid approach with very high-power short-duration (vHPSD, 90W) posteriorly and ablation-index guided HPSD (50W) anteriorly seems to be an optimal balance between efficiency and effectiveness for point-by-point pulmonary vein isolation (PVI).

The aim of the current study is to compare hybrid vHPSD/HPSD ablation to cryoballoon ablation (CBA) in patients with symptomatic atrial fibrillation (AF).

In this retrospective single center study we identified 110 consecutive patients who underwent their first PVI with either hybrid vHPSD/HPSD (n=54) or CBA (n=56) by experienced operators. In hybrid cases we used 90W for 4 seconds posteriorly and AI-guided 50W (target ablation index 500) anteriorly (Figure 1A). General anesthesia was used in all vHPSD/HPSD cases, while deep sedation was generally used in CBA cases (78.6%). We compared procedural efficacy, efficiency, safety and long-term outcomes.

Baseline characteristics of both groups were comparable (Figure 2), however, patients in the hybrid vHPSD/HPSD group had larger left atrial volume index (35, IQR 27-45 vs. 28, IQR 21-36 ml/m2, P=0.005). Complete PVI was achieved in all patients except two CBA cases (100% vs. 96.4%, P=0.50). First pass isolation rate was 79.6% in the hybrid group (Figure 1B). Procedure times (53, IQR 47-63 [hybrid] vs. 55, IQR 49-65 min [CBA], P=0.35) and cathlab times (97, IQR 88-105 [hybrid] vs. 95, IQR 84-103 min [CBA], P=0.51) were similar between groups , but fluoroscopy time was shorter in the vHPSD/HPSD group (3.9 [2.7, 5.6] vs. 11.9 [9.3, 14.9] min, P<0.001). There were 3 temporary phrenic nerve palsies (5.4%) in the CBA group which resolved within 1 year. No periprocedural complications were observed in the vHPSD/HPSD group. The 1-year freedom from any atrial tachyarrhythmias and AF after a single procedure was similar between groups (Figure 1C and 1D, respectively). During repeat procedure, durable PVI was comparable (57.9% [vHPSD/HPSD] vs. 73.5% [CBA] on PV-level, P=0.24).

Point-by-point PVI using RF energy has evolved continuously in the last decade with the advent of irrigation, wide antral circumferential ablation, contact-force, CLOSE-protocol, and HPSD. The hybrid use of vHPSD/HPSD seems to be an optimal RF ablation technique creating a good balance between procedural efficiency, efficacy and safety. Despite the availability of single-shot techniques, the versality of a focal RF ablation catheter renders its use still popular among experienced operators. We demonstrated that the use of hybrid vHPSD/HPSD ablation strategy was as fast and effective as CBA for achieving PVI.Figure 1  Figure 2