High-Power Short-Duration Ablation Versus Conventional Power Ablation in Pulmonary Vein Isolation in Patients With Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: High-power short-duration (HPSD) ablation has emerged as a promising alternative to conventional power delivery (CPD) for pulmonary vein isolation (PVI) among patients with atrial fibrillation (AF), though its efficacy, procedural efficiency, and safety profile remain uncertain.

Aims: To evaluate and compare the efficacy, procedural efficiency, and safety of HPSD versus CPD ablation strategies for PVI in patients with AF through a systematic review and meta-analysis of randomized controlled trials (RCTs).

Materials and methods: PubMed, Embase, Cochrane Library, and ClinicalTrials.Gov databases were systematically searched for RCTs comparing HPSD with CPD ablation for PVI in patients with AF. Random-effects models were used to pool hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI). R version 4.4.2 was used for statistical analysis.

Results: Eight RCTs with 1094 patients (558 undergoing HPSD and 536 undergoing CPD ablation) were included. No significant differences were found in freedom from arrhythmia during the follow-up period (HR: 0.77; 95% CI: 0.41-1.45; p = 0.424). AF recurrence did not differ (RR: 0.83; 95% CI: 0.59-1.16; p = 0.268) between groups. HPSD had a significantly shorter procedural (mean difference [MD]: -21.93 min; 95% CI: -31.34, -12.53; p < 0.001) and RF ablation times (MD: -13.87 min; 95% CI: -19.46, -8.27; p < 0.001). No differences were observed in fluoroscopy time and first-pass isolation for right and left pulmonary veins. There was no difference in esophageal lesion rates, pericardial, or neurological complications, but there was a higher incidence of steam pops in HPSD (RR: 3.42; 95% CI: 1.45-8.09; p = 0.005).

Discussion: Although HPSD ablation did not significantly improve freedom from arrhythmia or reduce AF recurrence compared to CPD, it demonstrated enhanced procedural efficiency, with shorter procedure and RF ablation times. Despite the higher rate of steam pops, the overall safety profile was similar between both groups.

Conclusion: High-power short-duration ablation for pulmonary vein isolation in atrial fibrillation demonstrated comparable efficacy and safety to conventional power delivery, with the added benefit of shorter procedure and RF ablation times. However, HPSD ablation was associated with increased occurrence of steam pops.