Meta-analysis comparing outcomes of high-power short-duration and low-power long-duration radiofrequency ablation for atrial fibrillation

OBJECTIVE: High power short duration (HPSD) ablation strategy is proposed to be more effective than low power long duration (LPLD) for radiofrequency ablation of atrial fibrillation. Although small trials abound, data from a large cohort are lacking. This meta-analysis compares all the existing studies comparing these two approaches to evaluate perceived advantages of one over the other. METHODS: A systematic search of PubMed, EMBASE, and Cochrane databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. RESULTS: Ablation settings varied widely across 20 studies comprising 2,136 patients who underwent HPSD and 1,753 patients who underwent LPLD. The pooled incidence of atrial arrhythmia recurrence after HPSD ablation was 20% [95% confidence interval (CI): 0.16–0.25; I2=88%]. Atrial arrhythmia recurrences were significantly less frequent with HPSD ablation (incidence risk ratio=0.66; 95% CI: 0.49–0.88; I2=72%; p=0.004). Procedural, fluoroscopy, and ablation times were significantly shorter with HPSD ablation. First-pass pulmonary vein isolations (PVIs) were significantly more [odds ratio (OR)=2.94; 95% CI: 1.50–5.77; I2=89%; p=0.002), and acute pulmonary vein reconnections (PVRs) were significantly lesser (OR=0.41; 95% CI: 0.28–0.62; I2=62%; p<0.001) in the HPSD group. Although radiofrequency energy was significantly higher, esophageal thermal injuries (ETI) were lower with HPSD ablation. Acute complications, including steam-pops, were rare and statistically similar in both the groups. CONCLUSION: HPSD ablation enables faster first-pass PVI with fewer PVRs, similar ETI rates, rare collateral damage, and lower recurrence of atrial arrhythmia in the long term than LPLD. Randomized controlled studies with a larger cohort are indicated both to confirm the benefit of HPSD ablation and standardize the ablation protocol.