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

Table 1 Trials and key evidence

Ref.	Design/population	Strategy/protocol	Key endpoints	Main findings (high level)
QDOT-FAST, 2019[6]	Prospective multicenter single-arm; PAF	vHPSD temperature-controlled (90 W/4 seconds algorithm)	Feasibility, acute performance, safety	Demonstrated feasibility and safety of 90 W/4 seconds temperature-controlled lesions; procedural efficiency vs historical controls
POWER PLUS, 2023[12]	Multicenter RCT; AF undergoing first PVI	Contiguous vHPSD 90 W/4 seconds vs conventional approach	Efficiency; 6-month efficacy; safety	Modest but significant reduction in procedure time; similar safety and 6-month efficacy; suggested hybrid approach may be optimal
SHORT-AF, 2023[10]	RCT; AF ablation with PVI	HPSD vs standard power-standard duration	Time to PVI; 12-month freedom from AF; ACE	Shorter time to PVI; higher freedom from AF at 12 months; trend toward increased ACE
POWER-FAST III, 2025[11]	RCT; PVI with endoscopic assessment	HPSD-70 (70 W, short) vs conventional 25-40 W	Arrhythmia recurrence (noninferiority); endoscopic esophageal lesions	Noninferior for recurrences; similar esophageal lesion incidence; reported symptomatic embolic events in HPSD-70 arm (technology/protocol-dependent signal)
QDOT-by-LAWT, 2024[3]	RCT noninferiority; first-time PAF	LA wall thickness-guided (vHPSD in thinner regions; standard/AI-guided in thicker) vs CLOSE	12-month effectiveness; efficiency	Noninferior 12-month outcomes; marked reductions in RF/procedure times; supports personalization for thicker regions
Sousa et al[9], 2023	RCT; PAF treated with AI	HPSD vs standard LPLD (AI-guided)	Noninferiority; efficiency	Reported noninferiority and faster procedures with shorter ablation times (protocol- and catheter-specific)

RCT: Randomized controlled trial; AF: Atrial fibrillation; PVI: Pulmonary vein isolation; vHPSD: Very high-power short-duration; HPSD: High-power short-duration; ACE: Atrial conduction enhancement; LA: Left atrium; AI: Ablation index; LPLD: Low-power long-duration.

Table 2 Meta-analyses comparing high-power short-duration/very high-power short-duration vs conventional low-power long-duration radiofrequency ablation

Ref.	Study type	Included studies (n)/patients (n)	RCT-only vs mixed	Main efficacy findings	Procedural efficiency	Safety findings	Key limitations
Ravi et al[8]	Systematic review and meta-analysis	13 studies/approximately 2900 patients	Mixed (RCT + observational)	Higher freedom from atrial arrhythmia with HPSD in pooled analysis	Significant reduction in procedure time, RF time, and fluoroscopy	No significant difference in major complications overall	Predominantly observational data; heterogeneous power protocols
Parlavecchio et al[18]	Meta-analysis	6 studies/approximately 1100 patients	Mixed	Trend toward improved arrhythmia-free survival with HPSD	Reduced RF and total procedure duration	Similar rates of major complications, including tamponade and stroke	Limited number of RCTs; protocol heterogeneity
Amin et al[17]	Meta-analysis	8 studies/approximately 1500 patients	RCT-focused (majority randomized)	HPSD noninferior to LPLD for arrhythmia recurrence	Significant reduction in RF time and procedural duration	No significant difference in overall complications or esophageal injury	Limited follow-up duration in some included trials

RCT: Randomized controlled trial; HPSD: High-power short-duration; RF: Radiofrequency; LPLD: Low-power long-duration.

Table 3 Comparison between high-power short-duration/very high-power short-duration radiofrequency ablation and pulsed-field ablation for atrial fibrillation

Characteristic	HPSD/vHPSD RF ablation	Pulsed-field ablation
Mechanism of action	Thermal injury through resistive and conductive heating	Non-thermal irreversible electroporation
Lesion formation	Wider, relatively shallower lesions; still dependent on tissue heating	Tissue-selective myocardial ablation
Procedural efficiency	Significant reduction in RF and procedure time compared with conventional RF	Generally among the shortest procedure times reported
Pulmonary vein isolation success	Excellent acute success (> 95% in most contemporary studies)	Excellent acute success (> 95%)
Freedom from AF recurrence	Non-inferior or improved compared with conventional RF	Comparable to HPSD/vHPSD in available comparative studies
Esophageal injury	Reduced compared with conventional RF but not eliminated	Very low incidence; major theoretical and clinical advantage
Phrenic nerve injury	Possible, particularly with right-sided lesions	Generally reduced due to tissue selectivity
Steam pops	Potential risk, especially at very high power	Not applicable
Cerebral embolic events	Reported in some HPSD trials (e.g., SHORT-AF, POWER-FAST III)	Cerebral lesions reported in some studies; long-term significance uncertain
Dependence on contact force and catheter stability	High	Lower
Operator dependence	Moderate to high	Potentially lower
Long-term evidence	Extensive clinical experience and long-term follow-up	Growing but still limited long-term experience
Technology maturity	Well established and widely available	Emerging and rapidly expanding
Current limitations	Thermal injury, protocol heterogeneity, operator dependence	Limited long-term data, evolving safety profile, device-specific learning curve

vHPSD: Very high-power short-duration; HPSD: High-power short-duration; RF: Radiofrequency; AF: Atrial fibrillation.