Background
Catheter ablation of atrial fibrillation (AF) aiming at pulmonary vein isolation (PVI) can be a time-demanding procedure. Ablation settings using high power and short energy (HPSD) application have been introduced into clinical practice allowing for fast and effective ablation procedures. We describe the application of HPSD protocols into our institutional routine clinical practice alongside optimized periprocedural patient management.

Methods
Consecutive patients undergoing first-time AF ablation with a contact-force sensing catheter and electroanatomic mapping with multielectrode catheters were analysed. The first patients underwent ablation with conventional energy settings (maximum of 35 W, reduction to 30 W at the posterior wall) (conventional group) alongside mapping with a circular mapping catheter. During the study course HPSD using 50 W under guidance of a lesion quality index along high-density mapping was utilized. (HPSD group). Finally, a novel catheter allowing for very high energy settings with temperature-controlled ablation (90 W over 4 seconds) was incorporated (vHPSD group) alongside high-density mapping. Procedural data as well as operating cycles (pre- and post-operative preparation time, time for venous access and mapping, ablation and validation timing) in the electrophysiological laboratory were analysed.

Results
A total of 217 patients were analyzed (conventional group: n=79, HPSD group: n=76, vHPSD group: n=62). PVI was achieved in all patients with occurrence of a total of 5 major complications (1 false aneurysm at groin access sites per group, 1 bleeding with transfusion in the conventional and vHPSD groups, respectively, p=1.0). Procedural times (“skin-to-skin”) (106.4±25.9 minutes (conventional) vs. 82.5±20.8 minutes (HPSD) vs 66.4±14.6 minutes (vHSPD), p=<0.00001) as well as total lab times (127.4±42.1 minutes vs. 106.5±35.0 minutes vs 92.5±24.0 minutes, p<0.0001) significantly shortened during the study course. A shortened ablation duration alongside optimized workflow for venous access and intracardiac mapping, was the main driver of workflow optimization (mean ablation times 1507.6±575.1 seconds (conventional) vs. 1035.1±330.9 seconds (HPSD) vs. 280.1±55.9 (vHPSD), p<0.00001).

Conclusion
The incorporation of HPSD and an optimized workflow led to shorter procedure durations without compromising effectiveness and safety in AF ablation.

Table 1 Procedural data

Data are presented as n (%) or mean±SD.

Figure 1 Analysis of laboratory timing
HPSD=high-power short-duration, vHPSD=very high-power short-duration.