Comparison between conventional radiofrequency and high-power short-duration ablation in the need for a second intervention for atrial fibrillation

Comparison between conventional radiofrequency and high-power short-duration ablation in the need for a second intervention for atrial fibrillation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 30 May 2025 V1 Latest version Share on Comparison between conventional radiofrequency and high-power short-duration ablation in the need for a second intervention for atrial fibrillation Authors : Elena Carrion Isaacs 0009-0000-2717-2679 , Maria Fuentes , Ana M. Ambrona , and Jesus Almendral [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174863355.51982225/v1 178 views 109 downloads Contents Abstract 3. 3 Pulmonary Vein Isolation and Reconnection Findings During Second Ablation Procedure Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Aims : This study compares the efficacy of conventional radiofrequency (RF) and high-power short-duration (HPSD) ablation in reducing the need for second interventions in patients with atrial fibrillation (AF). Methods : We retrospectively analyzed 701 patients undergoing RF ablation for AF. Patients were divided into two groups: 362 with conventional RF and 339 with HPSD ablation. The need for second interventions and pulmonary vein isolation (PVI) outcomes were assessed at 12 and 24 months. Results : The study demonstrated a significantly higher risk of reintervention in the conventional RF group compared to the HPSD group within the first two years (9.9% vs. 3.2%, P < 0.001). At 12 months, 1.5% of patients in the HPSD group required a second intervention compared to 5% in the conventional group (P = 0.009), with similar trends at 24 months ( 1.8% vs. 5%, P = 0.02). Kaplan-Meier analysis confirmed these findings. A greater proportion of patients in the HPSD group reached reintervention with all pulmonary veins isolated (45.5% vs. 29.6%, P = 0.167), and the mean percentage of reconnected pulmonary veins was lower in the HPSD group (18% vs. 33%, P = 0.048). Reconnection of the right inferior pulmonary vein (RIPV) was more frequent in the conventional RF group (62% vs. 25%, P = 0.021). Conclusions : HPSD ablation significantly reduces the need for a second intervention compared to conventional RF ablation, with a trend toward greater durability of PVI and comparable safety profiles. Comparison between conventional radiofrequency and high-power short-duration ablation in the need for a second intervention for atrial fibrillation Elena Carrion, MD | Maria Fuentes, MD | Ana M. Ambrona, MD | Jesus Almendral, MD, PhD, FESC | Department of Electrophysiology, HM Monteprincipe Hospital, Madrid, Spain. Department of Electrophysiology, HM Sanchinarro Hospital, Madrid, Spain. Faculty of Medicine, Universidad CEU San Pablo, Madrid, Spain. Jesus Almendral, Department of Electrophysiology, HM Monteprincipe Hospital, Boadilla del Monte, Madrid, 28660, Spain. Email: [email protected] ABSTRACT Aims : This study compares the efficacy of conventional radiofrequency (RF) and high-power short-duration (HPSD) ablation in reducing the need for second interventions in patients with atrial fibrillation (AF). Methods : We retrospectively analyzed 701 patients undergoing RF ablation for AF. Patients were divided into two groups: 362 with conventional RF and 339 with HPSD ablation. The need for second interventions and pulmonary vein isolation (PVI) outcomes were assessed at 12 and 24 months. Results : The study demonstrated a significantly higher risk of reintervention in the conventional RF group compared to the HPSD group within the first two years (9.9% vs. 3.2%, P < 0.001). At 12 months, 1.5% of patients in the HPSD group required a second intervention compared to 5% in the conventional group (P = 0.009), with similar trends at 24 months ( 1.8% vs. 5%, P = 0.02). Kaplan-Meier analysis confirmed these findings. A greater proportion of patients in the HPSD group reached reintervention with all pulmonary veins isolated (45.5% vs. 29.6%, P = 0.167), and the mean percentage of reconnected pulmonary veins was lower in the HPSD group (18% vs. 33%, P = 0.048). Reconnection of the right inferior pulmonary vein (RIPV) was more frequent in the conventional RF group (62% vs. 25%, P = 0.021). Conclusions : HPSD ablation significantly reduces the need for a second intervention compared to conventional RF ablation, with a trend toward greater durability of PVI and comparable safety profiles. KEYWORDS Electrophysiology, atrial fibrillation ablation, high-power short-duration radiofrequency, conventional radiofrequency, reintervention, pulmonary vein isolation, pulmonary vein reconnection patterns. 1 | INTRODUCTION Conventional RF ablation typically uses low power (25-30 W) over long durations (20-30 seconds) to generate transmural lesions. Recently, a high-power short-duration (HPSD) RF ablation technique has been developed, delivering higher power (45-50 W) over shorter periods (5-15 seconds). The goal of HPSD is to achieve rapid and efficient heating of the tissue, creating wider and more durable lesions with less energy dissipation to surrounding tissues. (1) HPSD RF has the potential to reduce procedure time and improve lesion consistency (1). Additionally, it may provide better long-term outcomes decreasing the likelihood of PV reconnection, which is a key factor in AF recurrence (2-5). Several factors influence the quality of RF lesions, such as power , ablation duration , and impedance drop , ablation index (AI) , lesion size index (LSI). (6-8). Despite the goal of achieving durable PVI with a single procedure, a substantial proportion of patients experience recurrence of AF, which may necessitate a second ablation procedure. The decision to perform a redo is often driven by persistent symptomatic recurrences that impact the patient’s quality of life. Importantly, even in the absence of a redo, patients may benefit from a significant reduction in arrhythmia burden, transitioning from persistent to paroxysmal AF or experiencing fewer symptomatic episodes. This improvement can enhance overall quality of life and potentially allow for the discontinuation of antiarrhythmic drugs. However, when recurrences significantly impair the patient’s well-being, a redo ablation is a critical step in regaining rhythm control and further reducing AF-related risks. Several studies have explored the safety, efficacy, and potential complications of both conventional RF and HPSD ablation techniques (5, 9, 10). However, there is limited information comparing the two methods in terms of their effectiveness in reducing the need for a second ablation procedure. Understanding the comparative benefits of these approaches is crucial for optimizing AF treatment and improving patient outcomes. The aim of the study was to evaluate the second procedures following two years post-ablation in terms of their incidence, findings, and resolution, comparing two ablation techniques: conventional RF and HPSD RF. 2 | METHODS 2. 1 Patients The study included patients who required a second PVI ablation for paroxysmal or persistent AF. Inclusion criteria were patients who had a first PVI ablation for AF between August 2015 and May 2021 and those who underwent a second procedure due to AF recurrence. Patients were excluded if the second procedure was not done at HM Hospitales or if PVs couldn’t be evaluated during the second procedure. 2.2 Study design A total of 701 patients who underwent catheter ablation between August 2015 and May 2021, were initially included in the database, divided into two groups: 362 patients treated with conventional radiofrequency and 339 patients treated with HPSD ablation. From this cohort, a secondary dataset was created by selecting only those patients who required a second ablation between August 2015 and June 2023, resulting in a sample of 93 patients of which 71 are from the conventional RF group and 22 from the HPSD group. Figure 1. To avoid time bias, given that patients treated with conventional RF have been followed for a longer period compared to those treated with HPSD, we analyzed the patients requiring a reintervention within the first two years after the initial ablation. This study was approved by the Ethical Committee. As this was a retrospective anonymized study, informed consent from the patients was not required. 2. 3 Data Analysis Data analysis focused on three domains: baseline characteristics of the study population, including antiarrhythmic drug use; timing of the second intervention, categorized within 1 or 2 years post-initial procedure; and procedural outcomes, encompassing the number and percentage of reconnected PVs and the anatomical distribution of gaps (e.g., anterior wall, posterior wall, roof, carina). 2. 4 Ablation Procedure A single transseptal puncture was used to introduce two catheters into the left atrium (LA): a 20-pole circular mapping catheter and an irrigated ablation catheter. A third quadripolar catheter served as a reference. Anticoagulation was maintained with heparin to achieve an activated clotting time (ACT) of ≥350 seconds. A 3D geometry of the LA and PV was created, predominantly with the circular catheter, while the ablation catheter was used for refining specific areas. An esophageal temperature probe was positioned to monitor esophageal temperature during RF applications. RF energy was delivered in unipolar mode between the ablation catheter and a distant skin electrode. Lesions were marked on the 3D geometry, and esophageal safety was ensured by terminating RF delivery if the esophageal temperature reached 38.5 °C. 2. 5 Pace and Map Maneuver The Pace and Map technique was employed to localize conduction gaps (11). Bipolar pacing was performed from within the PV to ensure consistent PV capture without direct LA capture. The circular catheter recorded activation times during pacing, and the ablation catheter was used to identify the earliest activation site along the atrial side of the ablation line. This site was targeted as the likely conduction gap. RF applications were deployed at identified gaps until bidirectional conduction block between the LA and PVs was confirmed. If conduction persisted, further mapping and ablation were conducted. In some cases, color-coded 3D activation maps were utilized for faster and more precise localization of conduction gaps. Gap locations were categorized into anatomical segments: anterior, posterior, roof, carina, floor, Marshall ligament and ridge. Concordance between Pace and Map findings and standard gap closure protocols was assessed by comparing anatomical and electroanatomical locations. Linear distances between gap sites identified through different methods were measured to evaluate consistency. This method ensures precise localization and effective closure of conduction gaps, enhancing the durability of PVI and reducing the likelihood of AF recurrence. 2. 6 Statistical Analysis Quantitative variables are expressed as mean ± SD, and qualitative variables as the percentages of patients. Comparisons of quantitative variables were made using the Student’s t-test, while qualitative variables were analyzed with chi-square tests or Fisher’s exact test, when appropriate. To evaluate the time to second intervention, Kaplan-Meier survival analysis was performed, and differences between the Conventional RF and HPSD groups were assessed using the log-rank test. Hazard ratios (HR) for the risk of a second intervention were calculated using Cox proportional hazards regression analysis, adjusting for relevant covariates. The significance threshold was set at P < 0.05, and 95% confidence intervals (CI) were calculated for key outcomes. All analyses were performed using SPSS version 26 (IBM Corp, Armonk, NY, USA). 3 | RESULTS 3. 1 Study Population A total of 701 patients who underwent catheter ablation between August 2015 and May 2021 were included in the initial cohort. The patients were divided into two groups: 362 (51.6%) treated with conventional RF and 339 (48.4%) treated with HPSD RF ablation. This study focuses exclusively on patients requiring redo ablations: 36 (9.9%) in conventional RF vs 11 (3.2%) in HPSD RF, emphasizing the outcomes and procedural differences between the two techniques. The baseline characteristics between both groups were similar with respect to age, sex, and comorbidities in patients undergoing repeat PVI procedures. (Table 1). 3. 2 Incidence of Second Ablation Out of the total cohort, 93 patients required a second ablation between August 2015 and June 2023, Figure 1. At the 12-month follow-up, 18 patients (5%) in the conventional RF group and 5 patients (1.5%) in the HPSD group required a second ablation (P = 0.009, Figure 2). At the 12–24-month interval follow-up, the number of second ablation procedures was 18 patients (5%) (P=0.02, Figure 2) in the conventional RF group, compared to 6 patients (1.8%) in the HPSD group. Overall, 36 out of 362 patients (9.9%; P<0.001) in the conventional RF group and 11 out of 339 patients (3.2%) in the HPSD group required a second ablation over the two-year follow-up. Figure 2, Table 1. The Kaplan-Meier survival analysis further demonstrated a statistically significant difference in freedom from second ablation between the two groups over the 24-month follow-up period (log-rank test, P < 0.001). Patients in the HPSD group had a significantly lower cumulative incidence of second ablation compared to those in the conventional RF group. Figure 3. However, the Cox proportional hazards model yielded a hazard ratio (HR) of 1.017 (95% CI: 0.672–1.540). 3. 3 Pulmonary Vein Isolation and Reconnection Findings During Second Ablation Procedure Table 2 summarizes the findings in the conventional RF group, 29.6% of patients had all pulmonary veins isolated, compared to 45.5% in the HPSD group (P = 0.167). The mean number of reconnected veins was 1.21 ± 1.1 in the RF group versus 0.77 ± 0.869 in the HPSD group (P = 0.093). Similarly, the percentage of reconnected veins was 32% in the conventional group compared to 18% in the HPSD group (P = 0.048). (Table 1). Considering individual veins, no significant differences were found in the left veins or in the right superior PV, Table 2. In contrast the right inferior PV was found to be reconnected more often after conventional ablation than after HPSD (62% vs 25%, P=0.021). Table 3 presents the location of gaps found in the redo procedure. No significant differences were observed in the location of the gaps between the left and right veins between the two techniques. However, there were significant differences in the Ridge + Marshall area when comparing the two groups (Conventional RF 28.2% vs 59.1% in HPSD, P=0.017). 4 | DISCUSSION 4. 1 Main Findings The main findings of this study included: 1) A significant reduction in the need of second interventions following the initial procedure with HPSD compared to the group treated with conventional RF in the two-year follow-up; 2) HPSD ablation resulted in longer freedom from AF recurrence at 24 months; 3) A significant tendency indicating that HPSD is more effective in PVI than conventional RF; 4) The RIPV was more often reconnected with conventional RF than HPSD RF; 5) A greater reconnection in the Ridge + Marshall gaps in the HPSD group compared to the conventional RF group; 6) The safety profile of both ablation strategies was comparable, with low complication rates. 4. 2 Need for Second Procedures Our study demonstrated that HPSD ablation significantly reduces the need for second interventions compared to conventional RF ablation over a two-year follow-up. Importantly, we observed that the proportion of relapses remained constant in both groups over the two years, suggesting that the risk of relapse does not increase over time, emphasizing the necessity for careful follow-up and management of AF patients post-ablation. In contrast, Okamatsu et al. (2021) (12) reported that redo procedures were required in 140 patients, with a higher percentage needing reintervention in the conventional power (CP) group (15%) compared to the high-power (HP) group (9%; P=0.01). They noted that the median time to atrial tachyarrhythmia recurrence was 354 days, with long-standing persistent AF patients showing a significantly higher percentage of redo procedures (25%) compared to those with paroxysmal (8%) and persistent AF (7%; P<0.0001). This highlights the influence of AF type on the need for reintervention and further supports our findings that HPSD ablation offers more favorable long-term outcomes in reducing the necessity for secondary procedures. 4. 3 Freedom from Atrial Fibrillation Recurrence Our findings showed that HPSD ablation resulted in longer freedom from AF recurrence at 24 months, with only 3.2% of patients experiencing recurrence compared to 9.9% in the conventional RF group. However, it is crucial to note that AF recurrence was inferred from the need for second interventions, potentially overlooking patients who may have experienced recurrence but did not undergo additional procedures due to effective management with antiarrhythmic medications. Our assessment of pharmacological management at 12 and 24 months revealed no significant differences between the two groups. This suggests that the lower need for repeat interventions in the HPSD group may indicate greater freedom from AF at 12 months (4) and 24 months and better long-term outcomes (13, 14). Our findings align with the meta-analysis by Ravi et al. (2020) (15), which demonstrated that HPSD ablation is associated with better procedural effectiveness compared to conventional RF ablation. Specifically, Ravi et al. reported a significantly higher rate of freedom from atrial arrhythmia with HPSD (OR 1.44, P = 0.009) and a reduced rate of acute PV reconnection (OR 0.56, P = 0.005). This reinforces our observation of lower reconnection rates in the right posterior carina gap with HPSD, supporting the trend toward improved PV isolation durability with HPSD ablation. In contrast, the PRIORI study (2024) (16) investigated pulsed field ablation (PFA) and reported a 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia of 85% for PFA compared to 79% for HPSD-RF (log-rank P = 0.160). This result indicates that, while our findings and those of Ravi et al. (15) favor HPSD ablation, the PRIORI (16) study does not support the superiority of HPSD, suggesting the need for further research to resolve these inconsistencies. Winkle et al. (2020) (17) reported that the number of PVs reconnected during redo ablation was associated with better long-term outcomes, showing 71.7% freedom from AF in patients with all veins reconnected. While our study did not stratify patients by the number of reconnected veins, the lower need for second interventions in the HPSD group likely reflects more durable lesion formation, reducing the overall recurrence and the need for additional procedures (15). 4. 4 Pulmonary Vein Isolation Durability We observed a greater durability of PVI during reinterventions in the HPSD group, indicating a reduced necessity for a second procedure. This observation aligns with our findings of a trend toward lower rates of PV reconnection in the HPSD group. Supporting this, Ravi et al. (15) reported a significantly higher first-pass isolation rate with HPSD ablation (OR 3.58, P < 0.001), suggesting that HPSD provides a more complete initial isolation of PVs, which could explain the decreased need for reinterventions observed in our cohort. Furthermore, Yavin et al. (2020) (18) demonstrated that patients undergoing HPSD ablation (45–50 W for 8–15 seconds) experienced substantially lower rates of chronic PV reconnections during redo procedures (16.6% vs. 52.2%; P = 0.03) compared to those treated with SPSD ablation (20–40 W for 20–30 seconds). Our findings support and expand upon the meta-analysis by Chen et al. (2020) (19), which reported that HPSD ablation yields a higher first-pass PVI rate (RR: 1.20) and a lower recurrence of atrial arrhythmias (RR: 0.73). This reinforces the notion that HPSD settings lead to more durable lesions, which reduce recurrence and improve long-term outcomes (2-4). Hansom et al. (2021) (20) observed a similar degree of lesion durability in the HPSD group, with 65% of patients undergoing repeat ablation requiring a second procedure compared to 59% in the low-power long-duration (LPLD) group. This discrepancy may be attributed to differences in technique or patient characteristics between the studies. 4. 5 Pulmonary Vein Reconnection Patterns Our findings highlighted that the RIPV was more frequently reconnected in the conventional RF group compared to the HPSD group. This suggests that HPSD settings may be more effective in maintaining long-term vein isolation, particularly in challenging areas such as the RIPV. Okamatsu et al. (2021) (12) found no statistically significant difference between HPSD and LPLD in overall reconnection rates, although reconnections in carinal segments were more frequent in the HPSD group. In our study, we similarly observed no statistically significant differences between the two techniques regarding the specific gaps analyzed. While our data demonstrated a trend toward lower overall reconnection rates in the HPSD group, individual gap locations, including the carinal and posterior segments, did not differ significantly between groups. These findings suggest that although HPSD may improve overall procedural durability, its impact on specific pulmonary vein gaps warrants further investigation to better understand its clinical implications. In contrast, Hansom et al. (20) reported a significantly higher rate of reconnection in the right carina with HPSD (46.7% in the HPSD group vs. 20.6% in the LPLD group, p = 0.035), attributing this to the more superficial lesions produced by HPSD. Both studies observed that reconnections were predominantly right-sided, particularly in carinal segments, emphasizing a potential vulnerability of these regions. Analysis of gap reconnection revealed a higher reconnection rate in the Ridge + Marshall areas in the HPSD group compared to the Conventional RF group, likely due to the need for deeper lesions, which is better achieved with Conventional RF. No significant differences were observed in other gaps, nor between right and left-sided gaps, even when stratified by specific locations. 4. 6 Safety, Ablation time and Long-term Outcome Several studies, including ours, indicate that HPSD ablation not only leads to improved AF-free survival rates but also reduces procedure times, with comparable safety profiles to conventional RF (4, 13, 14). The ability of HPSD to create durable lesions in shorter ablation times could be a key factor in its superior outcomes, making it an attractive option for long-term management of AF patients. In our cohort, the complication rates were similarly low in both groups, supporting the safety of the HPSD approach in clinical practice. Limitations This study has several limitations. The small sample size may have reduced statistical power, potentially leading to a type II error, where true differences might not have been detected. Additionally, some patients may have sought follow-up care at other hospitals, limiting our ability to fully assess the 24-month recurrence and second ablation rates. Although we conducted a thorough analysis of clinical and echocardiographic variables, no significant differences were found, but the presence of unstudied confounding factors cannot be ruled out. Further Research Future studies with larger populations, other forms of cardiac arrhythmias and extended follow-up periods are warranted to further validate these findings and confirm the long-term benefits of HPSD ablation. 5 | CONCLUSIONS HPSD ablation shows a significantly lower need for second interventions and longer freedom from AF recurrence compared to conventional RF ablation. Additionally, the durability of PVI was greater in the HPSD group, suggesting superior long-term outcomes. Both ablation strategies showed comparable safety profiles, with low complication rates. These findings highlight the potential of HPSD as a more effective and efficient therapeutic strategy for the management of AF, particularly in reducing the burden of reinterventions. ACKNOWLEDGMENTS We would like to express our sincere gratitude to Professor Santiago Angulo from Universidad CEU San Pablo for his statistical support. CONFLICTS OF INTEREST The authors declare no conflicts of interest. REFERENCES 1. Hong KL, Borges J, Glover B. Catheter ablation for the management of atrial fibrillation: current technical perspectives. Open Heart [Internet]. 2020;7(1). 2. Hijioka N, Kaneshiro T, Nehashi T, Amami K, Nodera M, Yamada S, et al. Procedural characteristics of pulmonary vein isolation with high-power short-duration setting compared to conventional setting. 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Supplementary Material File (figures manuscript final.pdf) Download 375.45 KB File (tables manuscript final.pdf) Download 93.75 KB Information & Authors Information Version history V1 Version 1 30 May 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical: catheter ablation – atrial fibrillation clinical: electrophysiology – atrial arrhythmias Authors Affiliations Elena Carrion Isaacs 0009-0000-2717-2679 Universidad CEU San Pablo Facultad de Medicina View all articles by this author Maria Fuentes Universidad CEU San Pablo Facultad de Medicina View all articles by this author Ana M. Ambrona Universidad CEU San Pablo Facultad de Medicina View all articles by this author Jesus Almendral [email protected] Universidad CEU San Pablo Facultad de Medicina View all articles by this author Metrics & Citations Metrics Article Usage 178 views 109 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Elena Carrion Isaacs, Maria Fuentes, Ana M. Ambrona, et al. Comparison between conventional radiofrequency and high-power short-duration ablation in the need for a second intervention for atrial fibrillation. Authorea . 30 May 2025. DOI: https://doi.org/10.22541/au.174863355.51982225/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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