High-power short-duration radiofrequency ablation for atrial fibrillation: There is still a country for “old men”

Abstract

High-power short-duration (HPSD) and very-HPSD (vHPSD) radiofrequency (RF) ablation have emerged as important advances in catheter ablation for atrial fibrillation (AF). By delivering higher power over shorter durations, these approaches aim to improve lesion quality, procedural efficiency, and clinical outcomes while maintaining procedural safety. The recent introduction of pulsed-field ablation (PFA) has challenged the role of thermal energy sources and raised questions regarding the future position of HPSD RF ablation in AF treatment. This narrative review summarizes the current evidence regarding the biophysical principles, procedural characteristics, efficacy, and safety of HPSD and vHPSD RF ablation. Data from mechanistic studies, randomized controlled trials, observational studies, meta-analyses, and contemporary consensus documents were reviewed, with particular focus on pulmonary vein isolation, posterior wall isolation, linear ablation, and comparisons with emerging PFA technologies. HPSD and vHPSD ablation generate lesions predominantly through resistive heating, producing broader and more homogeneous lesions while reducing RF application time. Randomized trials and meta-analyses consistently demonstrate shorter procedure duration, reduced RF delivery time, improved first-pass pulmonary vein isolation, and non-inferior or superior arrhythmia-free survival compared with conventional low-power long-duration RF ablation. Safety outcomes are generally comparable, although concerns regarding steam pops and cerebral embolic events remain dependent on catheter technology and procedural protocols. While PFA offers a non-thermal, tissue-selective alternative with promising safety and efficiency profiles, emerging evidence suggests that clinical efficacy remains largely comparable between PFA and HPSD/vHPSD strategies. HPSD and vHPSD RF ablation represent mature, effective, and efficient approaches for AF ablation, supported by extensive mechanistic and clinical evidence. Despite the rapid adoption of PFA, current data do not support the replacement of HPSD RF ablation. Rather, HPSD is likely to remain an important component of contemporary AF ablation, complementing emerging non-thermal technologies and providing a versatile strategy across a broad range of clinical scenarios.

Keywords: High-power short-duration; Atrial fibrillation; Catheter ablation; Radiofrequency; Lesion formation; Biophysics; Pulsed field ablation

Core Tip: High-power short-duration (HPSD) is the latest development in radiofrequency (RF) catheter ablation. HPSD has redefined the RF ablation landscape, offering proven advantages over low-power long-duration RF ablation in both safety and efficacy. However, there are still safety issues related to RF thermal effects. In addition, even when following standardized protocols, HPSD RF ablation remains operator-dependent. Pulsed field ablation (PFA) is an innovative, non-thermal ablation technique that employs pulsed electric fields to ablate myocardial tissue selectively, sparing adjacent non-cardiac structures. PFA seems more reproducible, reducing procedural time while maintaining non-inferior efficacy. In the era of PFA, HPSD RF ablation should therefore be viewed not as a technology being replaced, but rather as a mature and efficient strategy that will likely coexist with emerging non-thermal ablation modalities.