Network meta-analysis and systematic review comparing efficacy and safety between very high power short duration, high power short duration, and conventional radiofrequency ablation of atrial fibrillation

BACKGROUND

High-power short-duration (HPSD) atrial fibrillation (AF) ablation with a power of 40-50 W was proved to be safe and effective. Very high-power short-duration (vHPSD) AF ablation is a novel method using >50 W to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation.

METHODS

A literature search for studies that reported AF ablation outcomes, including short-term freedom from atrial arrhythmia, first-pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random-effects model of network meta-analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes.

RESULTS

A total of 29 studies with 9721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI]: 1.2-1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI: 0.78-2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI: 1.5-8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI: 0.61-8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques.

CONCLUSION

vHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques.

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.

Assessment of High-Power Catheter Ablation in Patients With Atrial Fibrillation: A Meta-Analysis

Background: High-power radiofrequency (RF) catheter ablation was considered as a promising alternative strategy to conventional-power ablation in the treatment of patients with atrial fibrillation (AF). This study sought to compare the efficacy and safety of high-power energy delivery to that of conventional-power setting in AF catheter ablation. Methods: We performed a systematic review of relevant literature in Pubmed, Embase, Cochrane library, and Google Scholar database. Sixteen eligible studies totaling 3,307 patients (1,929 for high-power ablation; 1,378 for conventional-power ablation) met inclusion criteria. Results: During a median 12 month follow-up, high-power ablation showed a significantly higher AF/atrial tachycardia-free survival rate in comparison with conventional-power ablation (risk ratio [RR] 1.09, 95% CI 1.02 to 1.15, p = 0.008). Notably, a high-power strategy convincingly decreased the procedure time (weighted mean difference [WMD] -46.11 min, 95% CI -59.15 to -33.07, p < 0.001) and RF ablation time (WMD -19.19 min, 95% CI -24.47 to -13.90, p < 0.001), along with reduced fluoroscopy time (WMD -7.82 min, 95% CI -15.13 to -0.68, p = 0.036). In addition, there was no perceptible difference in the potential risk of procedure-related complications between these two approaches (RR 0.81, 95% CI 0.48 to 1.37, p = 0.428). Conclusions: High-power RF catheter ablation was associated with an improvement in long-term sinus rhythm maintenance for treatment of AF, without exacerbating the risk of adverse events during the procedure. Impressively, high-power pulmonary vein isolation had the potential to shorten the application duration and minimize fluoroscopic exposure.

High-power short-duration ablation of atrial fibrillation: A contemporary review

Catheter ablation using radiofrequency (RF) energy has been widely used to treat patients with atrial fibrillation (AF). The optimal levels of power and duration to increase the success rate while minimizing complications have not been fully established. Different centers continue to use various power protocols for catheter ablation of AF. Herein, we present a comprehensive review of the impact of power output on efficacy and safety of RF ablation for AF. High-power short-duration (HPSD) ablation can be performed safely with similar procedural efficacy as low-power long-duration ablation strategy. HPSD ablation has the potential to shorten procedural and RF times and create more durable and localized lesions.

Efficacy of Catheter Ablation for Persistent Atrial Fibrillation

Background—

Catheter ablation (CA) is commonly performed for persistent atrial fibrillation, but few high-quality randomized controlled trials (RCTs) exist, leading to funding restrictions being proposed in several countries. We performed a random-effects meta-analysis of RCTs and non-RCTs to assess the efficacy of CA for persistent atrial fibrillation.

Methods and Results—

We systematically searched PubMed, EMBASE, CENTRAL, OpenGrey, and clinicaltrials.gov for RCTs and non-RCTs reporting clinical outcomes after CA for persistent atrial fibrillation. Forty-six eligible studies were identified containing 3819 patients. After a single procedure, CA significantly reduced the risk of recurrent atrial fibrillation compared with medical therapy (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.20–0.53; P <0.001). Outcomes were better if the pulmonary veins were encircled (OR, 0.26; 95% CI, 0.09–0.74; P =0.01), and electrical isolation reduced AF recurrence compared with purely anatomic encirclement (OR, 0.33; 95% CI, 0.13–0.86; P =0.02). Linear ablation within the left atrium (OR, 0.22; 95% CI, 0.10–0.49; P <0.001), but not complex fractionated atrial electrogram ablation (OR, 0.64; 95% CI, 0.35–1.18; P =0.15), significantly reduced AF recurrence. Results were not improved by performing more extensive linear lesion sets (OR, 0.77; 95% CI, 0.41–1.43; P =0.40) or from biatrial ablation (OR, 0.62; 95% CI, 0.31–1.24; P =0.17). Where data were available, the relative benefits seen held true both after a single or multiple procedure(s). Sensitivity analyses showed that inclusion of non-RCTs increased statistical power without biasing the calculated effect sizes.

Conclusions—

For patients with persistent atrial fibrillation, CA achieves significantly greater freedom from recurrent atrial fibrillation compared with medical therapy. The most efficacious strategy is likely to combine isolation of the pulmonary veins with limited linear ablation within the left atrium.

Nonsymptomatic myocardial injury after radiofrequency and cryoablation: a study of children and patients with congenital heart disease

The aim of this study was to investigate the degree of myocardial injury following catheter radiofrequency (RF) ablation (RFA) or cryoablation and its clinical significance in children and patients with congenital heart disease. Cardiac troponin T (cTnT) or cardiac troponin I (cTnI), creatine kinase (CK), and its cardiac isoenzyme MB (CK-MB) were measured in 269 patients who underwent catheter ablation (216 RFA, 53 cryoablation) just before the procedure and again 6 hours after the end of the procedure. Follow-up studies included echocardiography and 12 lead electrocardiographics (ECGs). No clinical, ECG, nor ECG signs of ischemia were detected. Biomarkers were increased in 57.7-75.5 %. A linear regression analysis illustrated the ablation target site and the number of RF applications as a function of higher cTnI and cTnT levels, with the maximum increase due to ventricular ablation and higher numbers of RF applications. No significant difference in cTnT levels after RFA or cryoablation were observed for AV nodal reentrant tachycardia procedures and no significant differences were observed after nonirrigated tip or irrigated tip RFA in atrial wall or ventricular wall ablation. Elevations in both troponin T and troponin I levels were commonly observed after ablation, especially in ventricular wall ablation as well as with increasing numbers of radiofrequency applications. However, unlike in patients with acute coronary syndrome, these elevated levels had no specific significance. Reference values for each ablation target site were proposed in order to potentially detect additional subclinical injuries to the coronary arteries.

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.