Pulsed field ablation versus very high power short duration radiofrequency ablation in atrial fibrillation: what is better?

Abstract Background The newly introduced non-thermal pulsed field ablation (PFA) is a promising technology for catheter ablation (CA) of atrial fibrillation (AF) with high acute success rates and good safety features. However studies have shown that very high power short duration (VHPSD) ablation is also highly effective and fast with potentially less arrhythmia recurrence compared to conventional radiofrequency ablation. Data comparing this two methods are lacking Objective The aim of this study is to compare two source of energy used for CA of AF in terms of procedural, clinical and outcome data Methods We conduced a retrospective observational study enrolling all patients (pts) from september 2021 to may 2023 who underwent CA of AF with PFA system and VHPSD. In the PFA group pulmonary veins isolation (PVI) was obtained using 2KV with eight application each vein, posterior wall isolation (PWI) of left atrium (LA) was obtained with application in the flower configuration of the catheter and then additional lesion were deployed at the operator’s discretion. In the VHPSD group the encircling of PV was obtained with 90W for 4 seconds radiofrequency pulses in posterior portions of the LA including LA PW, whereas 50W with ablation index target of 500 was used in the anterior portions of the PV and additional lesions. General anesthesia or deep sedation was carried out in all pts Results A total of 205 pts were included, n = 86 (42%) in the PFA group and N = 119 (58%) in the VHPSD group: paroxysmal (n = 6272%, N = 6454%), persistent (n = 1922%, N = 4336%), long standing persistent (n = 55%, N = 108%). PVI was successful in all pts and additional lesions were delivered in n = 26 (30%) in PFA group and N = 76 (64%) in HVPSD group, mostly at the PW (n = 2492%; N = 5066%). The PFA group revealed a shorter procedura duration (80 ± 29 min vs 108 ± 39 min; p = 0,00001) but longer fluoroscopic time (21 ± 8 min vs 14 ± 10 min; p = 0,00001). The VHPSD group revealed more complications (N = 76% vs n = 33%) but without statistically significant difference (p = 0,43), the most frequent in the PFA group was vascular access complications instead in the VHPSD group was post-procedural pericarditis. Only one patient in VHPSD group had major complication with a post-procedural stroke but without residual neurological deficits. At follow-up after median of 14 (26-6) months, n = 61 pts in the PFA group (71%) and N = 91 in the VHPSD group (76%) were free from atrial arrhythmia (p = 0,79). In both group 7 pts recurrenced as atypical atrial flutter (n = 728% PFA; N = 725% VHPSD; p = 0,061) Conclusion PFA and VHPSD are effective and safe to CA of AF with comparable arrhythmia recurrenses. However procedure duration with PFA is significantly shorter and therefore may be of potential benefit in particular for elderly and frail pts. Further research, including randomized controlled trials, is needed to validate and compare these techniques more comprehensively