High-Power Short-Duration vs Low-Power Long-Duration Ablation for Pulmonary Vein Isolation: A Substudy of the AWARE Randomized Controlled Trial

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Abstract
Background: Pulmonary vein isolations (PVI) are being performed using a high-power, short duration (HPSD) strategy. The purpose of this study was to compare the clinical efficacy and safety outcomes of a HPSD vs low-power long duration (LPLD) approach to PVI in patients with paroxysmal atrial fibrillation (AF). Methods: Patients were grouped according to a HPSD (≥40 W) or LPLD (≤ 35 W) strategy. The primary endpoint was the one-year recurrence of any atrial arrhythmia lasting ≥ 30 seconds, detected using three 14-day ambulatory continuous ECG monitoring. Procedural and safety endpoints were also evaluated. The primary analysis were regression models incorporating propensity scores yielding adjusted relative risk (RR a ) and mean difference (MD a ) estimates. Results: Of the 398 patients included in the AWARE Trial, 173 (43%) underwent HPSD and 225 (57%) LPLD ablation. The distribution of power was 50 W in 75%, 45 W in 20% and 40 W in 5% in the HPSD group, and 35W with 25W on the posterior wall in the LPLD group. The primary outcome was not statistically significant at 30.1% vs 22.2% in HPSD and LPLD group with RR a 0.77 (95% confidence interval [CI]) 0.55-1.10; p=0.165). The secondary outcome of repeat catheter ablation was not statistically significant at 6.9% and 9.8% (RR a 1.59 [95% CI 0.77-3.30]; p=0.208) respectively. The incidence of any ECG documented AF during the blanking period was numerically lower in the HPSD group: 1.7% vs 8.0% (RR a 3.95 [95% CI 1.00-15.61; p=0.049). The total procedure time was significantly shorter in the HPSD group (MD a 97.5 minutes [95% CI 84.8-110.4)]; p<0.0001) with no difference in adjudicated serious adverse events. Conclusions: A HPSD strategy was associated with significantly shorter procedural times with similar efficacy in terms of clinical arrhythmia recurrence. Importantly, there was no signal for increased harm with a HPSD strategy. Graphical Non-standard Abbreviations and Acronyms: HPSD: High-Power Short Duration; LPLD: Low-Power Long Duration; QOL: Quality of Life; WACA: wide area circumferential ablation; PVI: Pulmonary Vein Isolation; AF: Atrial Fibrillation Clinical Perspective: What is known: -The optimal power and duration of ablation lesions to produce durable pulmonary vein isolation remain unclear. -Nonrandomized studies have suggested clinical efficacy with high-power short duration radiofrequency ablation vs low-power long duration. What this study adds: -In this large substudy of the AWARE Trial, a high-power short duration radiofrequency ablation strategy was found to be similarly effective as a low-power long duration strategy with no difference in time to first recurrence of any AF lasting ≥ 30 seconds. -Procedural were substantially reduced with high-power short duration ablation with no significant difference in overall complication rates.

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