High power short duration (HPSD) versus lower power longer duration (LPLD) atrial fibrillation ablation: a multi-centre randomised controlled trial (HiLo-HEAT study)

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background  Lower power (25W) longer duration (LPLD) radiofrequency (RF) ablation has conventionally been used on the posterior wall during pulmonary vein isolation (PVI) for atrial fibrillation (AF), to attenuate the risk of esophageal thermal injury (ETI). High power (40-50 W) short duration (HPSD) RF ablation results in shorter procedural times with no increase in ETI. However evidence had been limited by non-randomised studies. Purpose  To compare HPSD versus LPLD ablation and the effects on esophageal thermal injury (ETI) and procedural outcomes. Methods  In this multi-centre, prospective, randomised control trial, 88 patients with paroxysmal/persistent AF undergoing their first RF ablation procedure were randomised 1:1 to HPSD or LPLD ablation. Anterior wall ablation was done in both arms using 40-50 W, with ablation target of AI 500-500/ LSI 5-5.5. Posterior wall ablation was done using 40-50W (HPSD group) versus 25 W (LPLD group), with target AI 400/ LSI 4. Ablation involves wide antral circumferential PVI using contact force sensing ablation catheters, with additional ablation lines as per operator discretion. Circa multi-sensor esophageal temperature monitoring (ETM) probe was utilized. Endoscopy was performed within 24 hours to assess for ETI. The primary outcome was incidence of ETI, with secondary outcomes including acute procedural endpoints. Results  Mean age of the cohort was 61+/-9 years, with 31% females. 36 (41%) had PAF. PVI was achieved in 100% of patients, with posterior wall isolation (PWI) added in 19 PsAF patients (21.6%). There were more hypertensive patients in HPSD (p = 0.02). Significant esophageal luminal temperature rises (≥ 38 c) were seen in 93.2% of patients, with no difference between groups (p = 0.69). First pass isolation rates for left and right PVs were 85% and 61% respectively, with similar rates in both groups (p = 0.37, p = 0.65 respectively). HPSD group had shorter RF time (1613 vs 2303 secs, p <0.04), and fluoroscopy times (11.4 vs 13.1 mins, p = 0.05). Procedural times were lower in HPSD, although not significant (133.7 vs 150.8 mins, p = 0.10). Post ablation endoscopy showed 4 cases of ETI (4.5%), with equal occurrence in HPSD and LPLD (p = 1.0). All ETIs were class 2a (superficial ulcer), and treated with PPI therapy. Esophageal injuries not attributable to RF ablation occurred in 9 (10%), with no difference between groups (p = 0.29). There was no difference in AF recurrence between the 2 groups (post 3 months blanking period) after a mean follow up of 6.3 months (p = 0.71). Conclusion  HPSD ablation was associated with lower RF ablation and fluoroscopy times compared to LPSD, with comparably low rates of ETI on post ablation endoscopy. Our findings suggest that HPSD ablation is a safe and efficacious approach to PVI. However clinicians should be cognisant of the potential injury risk related to esophageal instrumentation from transesophageal echo/ ETM probes.