Comparison of very high-power short-duration, high-power short-duration, and low-power long-duration radiofrequency ablation for atrial fibrillation: A systematic review and network meta-analysis.

Abstract

The optimal power and duration settings for radiofrequency (RF) atrial fibrillation (AF) ablation to improve efficacy and safety is unclear. We compared low-power long-duration (LPLD), high-power short-duration (HPSD), and very HPSD (vHPSD) RF settings for AF ablation. This network meta-analysis (NMA) was structured according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Observational and randomized studies were included. Eligible studies compared outcomes in AF patients who underwent first-time RF ablation with the following settings: vHPSD (70-90W, 3-10 s), HPSD (45-60W, 5-10 s), or LPLD (20-40W, 20-60 s). Thirty-six studies comprising 10,375 patients were included (33% female). Frequentist NMA showed LPLD tended toward a lower odds of freedom from arrhythmia (FFA) versus HPSD (OR 0.93, 95% CI 0.86-1.00). There was no difference in FFA between vHPSD versus HPSD. Splitwise interval estimates showed a lower odds of FFA in LPLD versus vHPSD on direct (OR 0.78, 95% CI 0.65-0.93) and network estimates (OR 0.85, 95% CI 0.73-0.98). Frequentist NMA showed less total procedural (TP) time with HPSD versus LPLD (generic variance 1.06, 95% CI 0.83 to 1.29) and no difference between HPSD versus vHPSD. This NMA shows improved procedural times in HPSD and vHPSD versus LPLD. Although HPSD tended toward improved odds of FFA compared to LPLD, the overall result was not statistically significant. The odds of FFA in LPLD was lower versus vHPSD on direct and network estimates on splitwise interval analysis. Large prospective head-to-head randomized trials are needed to validate HPSD and vHPSD settings.