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. 2023 Mar 30;25(3):880-888.
doi: 10.1093/europace/euac243.

Very high-power short-duration ablation for pulmonary vein isolation utilizing a very-close protocol-the FAST AND FURIOUS PVI study

Christian-H Heeger  1   2 , Makoto Sano  1   3 , Sorin Ștefan Popescu  1 , Behnam Subin  1 , Marcel Feher  1 , Huong-Lan Phan  1 , Bettina Kirstein  1 , Julia Vogler  1 , Charlotte Eitel  1 , Sascha Hatahet  1 , Karl-Heinz Kuck  1   4 , Roland R Tilz  1   2   4
Affiliations

Very high-power short-duration ablation for pulmonary vein isolation utilizing a very-close protocol-the FAST AND FURIOUS PVI study

Christian-H Heeger et al. Europace. .

Abstract

Aims: The very high-power short-duration (vHP-SD) radiofrequency (RF) ablation concept of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective, and faster procedures. Utilizing conventional ablation, the 'close protocol' has been verified. Since lesion formation of vHP-SD ablation creates wider but shallower lesions we adapted the close protocol to an individualized and tighter 'very-close protocol' of 3-4 mm of inter-lesion distance (ILD) at the anterior and 5-6 mm at the posterior aspect of the left atrium using vHP-SD only. Here, we evaluated the safety and efficacy of vHP-SD ablation for PVI utilizing a very-close protocol in comparison with standard ablation.

Methods and results: A total of 50 consecutive patients with symptomatic AF were treated with a very-close protocol utilizing vHP-SD (vHP-SD group). The data were compared with 50 consecutive patients treated by the ablation-index-guided strategy (control group). The mean RF time was 352 ± 81 s (vHP-SD) and 1657 ± 570 s (control, P < 0.0001), and the mean procedure duration was 59 ± 13 (vHP-SD) and 101 ± 38 (control, P < 0.0001). The first-pass isolation rate was 74% (vHP-SD) and 76% (control, P = 0.817). Severe adverse events were reported in 1 (2%, vHP-SD) and 3 (6%, control) patients (P = 0.307). A 12-month recurrence-free survival was 78% (vHP-SD) and 64% (control, P = 0.142). PVI durability assessed during redo-procedures was 75% (vHP-SD) vs. 33% (control, P < 0.001).

Conclusions: PVI solely utilizing vHP-SD via a very-close protocol provides safe and effective procedures with a high rate of first-pass isolations. The procedure duration and ablation time were remarkably low. A 12-month follow-up and PVI durability are promising.

Keywords: Acute efficacy; Atrial fibrillation; High-power short-duration; Pulmonary vein isolation; Radiofrequency.

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Conflict of interest statement

Conflict of interest: C.-H.H. received travel grants and research grants from Boston Scientific, Biosense Webster, and Cardiofocus, and Speaker’s Honoraria from Boston Scientific, Biosense Webster, and Cardiofocus. R.R.T. is a consultant of Boston Scientific, Biotronik, and Biosense Webster, and received Speaker’s Honoraria from Biosense Webster, Medtronic, Boston Scientific, and Abbot Medical. K.-H.K. reports grants and personal fees from Abbott Vascular, Medtronic, Biosense Webster outside submitted work. All other authors have no relevant disclosures. C.E. received travel grants and research grants by Boston Scientific, Biosense Webster, Medtronic, Abbott, and Speaker’s Honoraria from Boston Scientific, Biosense Webster Medtronic, and Abbott. All other authors none declared.

Figures

Figure 1
Figure 1
QDOT micro catheter in QMODE± utilizing the very-close protocol: A–F: posterior aspect: three-dimensional electroanatomic reconstruction (CARTO 3, UNIVIEW module, Biosense Webster) of the left atrium in right anterior oblique (left) and right lateral (right) view. Please note the deployment of very high-power short-duration applications by 90W/4 s. At the posterior area an ILD of 5–6 mm was targeted. G–L: anterior aspect: Three-dimensional electroanatomic reconstruction (CARTO 3, UNIVIEW module, Biosense Webster) of the left atrium in posterior anterior (left) and left lateral (right) view. Please note the deployment of very-high power short duration applications by 90 W/4 s (QMODE+ mode, red–white tags) at the anterior aspect of the left pulmonary veins. At the anterior area an ILD of 3–4 mm was targeted.
Figure 2
Figure 2
Final lesions set. Three-dimensional electroanatomic reconstruction (CARTO 3, UNIVIEW module, Biosense Webster) of the left atrium in posterior anterior (left) and anterior posterior (right) view. Please note the two circles of very-high power short duration applications by 90 W/4 s (QMODE+ mode, red–white tags) encircling the right and left pulmonary veins.
Figure 3
Figure 3
Periprocedural data: periprocedural duration: (A) procedure time; (B) left atrial dwelling time; (C) total radiofrequency time, vHP-SD group compared with the control group.
Figure 4
Figure 4
12-month follow-up and findings of repeat procedures. (A) Kaplan–Meier estimates with 12-month follow-up after the index PVI utilizing very-high power short duration applications by 90 W/4 s (QMODE+) only and the control group. No statistical differences were found concerning 12-month freedom from atrial tachyarrhythmias. (B) Comparison of pulmonary vein durability assessed during repeat procedures of n = 7 (very high-power short-duration group) and n = 9 (control) patients. All four PVs were found to be isolated in 57% of very high-power short-duration group and 0% of control group patients.
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