Biophysical Behavior of Very High-Power Short-Duration Radiofrequency Ablation in Pulmonary Vein Isolation: Fast but Gently-Implications for a Successful Procedure

The very high-power short-duration (vHP-SD) ablation strategy is an alternative for pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF). However, the acute procedural biophysical behavior of successful lesion creation by means of this technique is still unexplored. We performed a retrospective case-control study aimed at evaluating the behavior of vHP-SD ablation parameters with the QDOT MICRO (TM) ablation catheter (Biosense Webster) compared with standard radiofrequency (RF) ablation with the THERMOCOOL SMARTTOUCH (R) ablation catheter. Twenty consecutive cases of symptomatic PAF treated with the QDOT MICRO (TM) ablation catheter from December 2022 to March 2023 were compared with cases treated with the standard technique. The acute procedural success of PVI was obtained in all cases with 2192 RF applications, and no adverse events occurred. Compared with the controls, vHP-SD cases featured a significant reduction in procedural time (47 +/- 10 vs. 56 +/- 12 min, p = 0.023), total RF time (3.8 [CI 3.4-4.6] vs. 21.2 [CI 18.4-24.9] min, p < 0.001), ablation phase time (25 +/- 5 vs. 39 +/- 9 min, p < 0.001), and irrigation volume (165 [CI 139-185] vs. 404 [CI 336-472] ml, p < 0.001). In vHP-SD RF ablation, a contact force of 5 g minimum throughout the 4 s of RF application appeared to be statistically significant in terms of an impedance drop of at least 10 Ohm (OR 2.63 [CI 1.37; 5.07], p = 0.003). In contrast, in the control group, the impedance drop depended linearly on the contact force. This suggests a different biophysical behavior of vHP-SD ablation. A maximum temperature and minimum contact force of >5 g independently predicted an effective impedance drop in vHP-SD. Increasing the contact force over 5 g during 4 s of vHP RF application might not be necessary to achieve a successful lesion.