Atrial Fibrillation Ablation: Are We Still Looking for the Best Shot?

Faganello, Lucas Simonetto; Pimentel, Mauricio

doi:10.36660/abc.20250396

Keywords
Atrial Fibrillation; Ablation

Palavras-chave
Fibrilação Atrial; Ablação

Keywords
Atrial Fibrillation; Ablation

Palavras-chave
Fibrilação Atrial; Ablação

Atrial fibrillation (AF) is independently associated with increased risks of mortality, stroke, heart failure, impaired quality of life, and cognitive decline. Rhythm control has proven superior to rate control in reducing cardiovascular outcomes, with catheter ablation demonstrating greater efficacy than antiarrhythmic drug therapy.¹–³ Continuous advances in techniques and technologies have progressively established ablation as a cornerstone in the management of AF.

In recent years, 3D mapping and point-by-point ablation have evolved significantly with the introduction of contact force-sensing catheters and the development of lesion quality metrics, such as the Ablation Index and Lesion Size Index. These improvements have translated into better outcomes, reduced procedure times, and enhanced safety.³–⁵ Pulmonary vein isolation remains the cornerstone of invasive AF treatment, with radiofrequency (RF) point-by-point ablation still being the most widely used technique despite the emergence of alternative energy sources. Procedural success relies on delivering continuous, irreversible, and transmural lesions encircling the pulmonary veins while sparing adjacent structures, such as the esophagus and phrenic nerve.

The high-power short-duration (HPSD) technique has emerged as an alternative to conventional RF ablation, aiming to produce more superficial but wider lesions by enhancing resistive heating while minimizing conductive heating, thereby shortening ablation time.⁶ Building upon this concept, the very high-power short-duration (VHPSD) technique was recently introduced, delivering 90 watts over 4 seconds. This approach has demonstrated a favorable safety profile and high first-pass isolation rates.⁷

Pulsed-field ablation (PFA) is a non-thermal modality based on irreversible electroporation, which uses high-energy, ultra-short electrical pulses to create permanent transmural lesions while preserving surrounding tissues.⁸ The absence of esophageal injury and its potentially catastrophic complications has generated considerable interest in the electrophysiology community. Registry data suggest that PFA provides favorable outcomes with low complication rates.⁹–¹⁰ In a randomized clinical trial directly comparing PFA with conventional RF ablation, no significant differences were found between the two techniques.¹¹ Furthermore, a recent observational study comparing PFA and HPSD showed shorter procedure times and lower AF recurrence rates with PFA.¹²

In this issue of Arquivos Brasileiros de Cardiologia, an elegant meta-analysis compares the outcomes of PFA and VHPSD for AF ablation.¹³ The analysis includes four observational studies comprising a total of 605 patients. Both techniques demonstrated comparable success rates and similar complication rates. PFA was associated with a shorter total procedure time but a longer fluoroscopy duration. This study is clinically relevant as it provides a timely comparison between two contemporary ablation strategies. However, a key limitation is that only observational studies were included; no randomized clinical trials have yet directly compared PFA and VHPSD. These findings are in line with those of another recent meta-analysis addressing the same question.¹⁴

Catheter ablation is now firmly established as the most effective rhythm control strategy for AF. The continuous development of novel techniques and the search for the optimal ablation strategy remain highly relevant. There is a clear need for robust randomized clinical trials comparing these technologies. Additionally, considering variations in cost and accessibility, cost-effectiveness analyses will be essential to guide decision-making. In this context, where the Sociedade Brasileira de Arritmias Cardíacas has recently succeeded in securing approval for complex ablations within the Brazilian public health system (SUS), defining the most effective ablation strategy will be pivotal for shaping public health policy and optimizing resource allocation.¹⁵

Short Editorial related to the article:
Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis

References

¹ Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-16. doi: 10.1056/NEJMoa2019422.
» https://doi.org/10.1056/NEJMoa2019422
² Osorio J, Miranda-Arboleda AF, Velasco A, Varley AL, Rajendra A, Morales GX, et al. Real-World Data of Radiofrequency Catheter Ablation in Paroxysmal Atrial Fibrillation: Short- and Long-Term Clinical Outcomes from the Prospective Multicenter REAL-AF Registry. Heart Rhythm. 2024;21(11):2083-91. doi: 10.1016/j.hrthm.2024.04.090.
» https://doi.org/10.1016/j.hrthm.2024.04.090
³ Ternes CMP, Rohde LE, Forno AD, Lewandowski A, Nascimento HG, Odozynski G, et al. The Southern Brazilian Registry of Atrial Fibrillation (SBR-AF Registry): Predictors of Atrial Arrhythmia Recurrence after First-Time Catheter Ablation. Arq Bras Cardiol. 2025;122(1):e20240246. doi: 10.36660/abc.20240246.
» https://doi.org/10.36660/abc.20240246
⁴ Afzal MR, Chatta J, Samanta A, Waheed S, Mahmoudi M, Vukas R, et al. Use of Contact Force Sensing Technology during Radiofrequency Ablation Reduces Recurrence of Atrial Fibrillation: A Systematic Review and Meta-Analysis. Heart Rhythm. 2015;12(9):1990-6. doi: 10.1016/j.hrthm.2015.06.026.
» https://doi.org/10.1016/j.hrthm.2015.06.026
⁵ Hussein A, Das M, Riva S, Morgan M, Ronayne C, Sahni A, et al. Use of Ablation Index-Guided Ablation Results in High Rates of Durable Pulmonary Vein Isolation and Freedom from Arrhythmia in Persistent Atrial Fibrillation Patients: The PRAISE Study Results. Circ Arrhythm Electrophysiol. 2018;11(9):e006576. doi: 10.1161/CIRCEP.118.006576.
» https://doi.org/10.1161/CIRCEP.118.006576
⁶ Leshem E, Zilberman I, Tschabrunn CM, Barkagan M, Contreras-Valdes FM, Govari A, et al. High-Power and Short-Duration Ablation for Pulmonary Vein Isolation: Biophysical Characterization. JACC Clin Electrophysiol. 2018;4(4):467-79. doi: 10.1016/j.jacep.2017.11.018.
» https://doi.org/10.1016/j.jacep.2017.11.018
⁷ Heeger CH, Sano M, Popescu SȘ, Subin B, Feher M, Phan HL, et al. Very High-Power Short-Duration Ablation for Pulmonary Vein Isolation utilizing a Very-Close Protocol-the FAST AND FURIOUS PVI Study. Europace. 2023;25(3):880-8. doi: 10.1093/europace/euac243.
» https://doi.org/10.1093/europace/euac243
⁸ Reddy VY, Neuzil P, Koruth JS, Petru J, Funosako M, Cochet H, et al. Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation. J Am Coll Cardiol. 2019;74(3):315-26. doi: 10.1016/j.jacc.2019.04.021.
» https://doi.org/10.1016/j.jacc.2019.04.021
⁹ Chun KJ, Miklavčič D, Vlachos K, Bordignon S, Scherr D, Jais P, et al. State-of-the-Art Pulsed Field Ablation for Cardiac Arrhythmias: Ongoing Evolution and Future Perspective. Europace. 2024;26(6):euae134. doi: 10.1093/europace/euae134.
» https://doi.org/10.1093/europace/euae134
¹⁰ Scanavacca M, Pisani C. Impact of Pulsed Field Ablation on Atrial Fibrillation. Arq Bras Cardiol. 2024;121(10):e20240565. doi: 10.36660/abc.20240565.
» https://doi.org/10.36660/abc.20240565
¹¹ Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, et al. Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2023;389(18):1660-71. doi: 10.1056/NEJMoa2307291.
» https://doi.org/10.1056/NEJMoa2307291
¹² Santos RR, Amador R, Santos PG, Matos D, Rodrigues G, Carmo J, et al. Atrial Fibrillation Catheter Ablation: Electroporation Against High-Power Short Duration Radiofrequency. Arq Bras Cardiol. 2025;122(2):e20240542. doi: 10.36660/abc.20240542.
» https://doi.org/10.36660/abc.20240542
¹³ Iqbal A, Amador WFO, Cevallos-Cueva M, Ahmad M, Alarcón JAP, Diniz RV. Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis. Arq Bras Cardiol. 2025; 122(7):e20240845. DOI: https://doi.org/10.36660/abc.20240845i
» https://doi.org/10.36660/abc.20240845i
¹⁴ Bulhões E, Mazetto RASV, Vanio AL Jr, Defante MLR, Feitoza L, Guida C, et al. Comparing Pulsed Field Ablation with Very High-Power and High-Power Short-Duration Radiofrequency Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Interv Card Electrophysiol. 2025;68(3):691-700. doi: 10.1007/s10840-024-01970-0.
» https://doi.org/10.1007/s10840-024-01970-0
¹⁵ Brasil. Ministério da Saúde. Portaria SECTICS/MS n° 35, de 27 de maio de 2025. Autoriza o repasse referente às ações e serviçospúblicos de saúde por meio de transferências fundo a fundo, em parcela única, para o custeio da Média e Alta Complexidade em Saúde. Diário Oficial da União. 29 May 2025.

Publication Dates

Publication in this collection
25 Aug 2025
Date of issue
2025

History

Received
02 June 2025
Reviewed
11 June 2025
Accepted
11 June 2025

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹ Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-16. doi: 10.1056/NEJMoa2019422.
» https://doi.org/10.1056/NEJMoa2019422

[2] ² Osorio J, Miranda-Arboleda AF, Velasco A, Varley AL, Rajendra A, Morales GX, et al. Real-World Data of Radiofrequency Catheter Ablation in Paroxysmal Atrial Fibrillation: Short- and Long-Term Clinical Outcomes from the Prospective Multicenter REAL-AF Registry. Heart Rhythm. 2024;21(11):2083-91. doi: 10.1016/j.hrthm.2024.04.090.
» https://doi.org/10.1016/j.hrthm.2024.04.090

[3] ³ Ternes CMP, Rohde LE, Forno AD, Lewandowski A, Nascimento HG, Odozynski G, et al. The Southern Brazilian Registry of Atrial Fibrillation (SBR-AF Registry): Predictors of Atrial Arrhythmia Recurrence after First-Time Catheter Ablation. Arq Bras Cardiol. 2025;122(1):e20240246. doi: 10.36660/abc.20240246.
» https://doi.org/10.36660/abc.20240246

[4] ⁴ Afzal MR, Chatta J, Samanta A, Waheed S, Mahmoudi M, Vukas R, et al. Use of Contact Force Sensing Technology during Radiofrequency Ablation Reduces Recurrence of Atrial Fibrillation: A Systematic Review and Meta-Analysis. Heart Rhythm. 2015;12(9):1990-6. doi: 10.1016/j.hrthm.2015.06.026.
» https://doi.org/10.1016/j.hrthm.2015.06.026

[5] ⁵ Hussein A, Das M, Riva S, Morgan M, Ronayne C, Sahni A, et al. Use of Ablation Index-Guided Ablation Results in High Rates of Durable Pulmonary Vein Isolation and Freedom from Arrhythmia in Persistent Atrial Fibrillation Patients: The PRAISE Study Results. Circ Arrhythm Electrophysiol. 2018;11(9):e006576. doi: 10.1161/CIRCEP.118.006576.
» https://doi.org/10.1161/CIRCEP.118.006576

[6] ⁶ Leshem E, Zilberman I, Tschabrunn CM, Barkagan M, Contreras-Valdes FM, Govari A, et al. High-Power and Short-Duration Ablation for Pulmonary Vein Isolation: Biophysical Characterization. JACC Clin Electrophysiol. 2018;4(4):467-79. doi: 10.1016/j.jacep.2017.11.018.
» https://doi.org/10.1016/j.jacep.2017.11.018

[7] ⁷ Heeger CH, Sano M, Popescu SȘ, Subin B, Feher M, Phan HL, et al. Very High-Power Short-Duration Ablation for Pulmonary Vein Isolation utilizing a Very-Close Protocol-the FAST AND FURIOUS PVI Study. Europace. 2023;25(3):880-8. doi: 10.1093/europace/euac243.
» https://doi.org/10.1093/europace/euac243

[8] ⁸ Reddy VY, Neuzil P, Koruth JS, Petru J, Funosako M, Cochet H, et al. Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation. J Am Coll Cardiol. 2019;74(3):315-26. doi: 10.1016/j.jacc.2019.04.021.
» https://doi.org/10.1016/j.jacc.2019.04.021

[9] ⁹ Chun KJ, Miklavčič D, Vlachos K, Bordignon S, Scherr D, Jais P, et al. State-of-the-Art Pulsed Field Ablation for Cardiac Arrhythmias: Ongoing Evolution and Future Perspective. Europace. 2024;26(6):euae134. doi: 10.1093/europace/euae134.
» https://doi.org/10.1093/europace/euae134

[10] ¹⁰ Scanavacca M, Pisani C. Impact of Pulsed Field Ablation on Atrial Fibrillation. Arq Bras Cardiol. 2024;121(10):e20240565. doi: 10.36660/abc.20240565.
» https://doi.org/10.36660/abc.20240565

[11] ¹¹ Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, et al. Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2023;389(18):1660-71. doi: 10.1056/NEJMoa2307291.
» https://doi.org/10.1056/NEJMoa2307291

[12] ¹² Santos RR, Amador R, Santos PG, Matos D, Rodrigues G, Carmo J, et al. Atrial Fibrillation Catheter Ablation: Electroporation Against High-Power Short Duration Radiofrequency. Arq Bras Cardiol. 2025;122(2):e20240542. doi: 10.36660/abc.20240542.
» https://doi.org/10.36660/abc.20240542

[13] ¹³ Iqbal A, Amador WFO, Cevallos-Cueva M, Ahmad M, Alarcón JAP, Diniz RV. Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis. Arq Bras Cardiol. 2025; 122(7):e20240845. DOI: https://doi.org/10.36660/abc.20240845i
» https://doi.org/10.36660/abc.20240845i

[14] ¹⁴ Bulhões E, Mazetto RASV, Vanio AL Jr, Defante MLR, Feitoza L, Guida C, et al. Comparing Pulsed Field Ablation with Very High-Power and High-Power Short-Duration Radiofrequency Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Interv Card Electrophysiol. 2025;68(3):691-700. doi: 10.1007/s10840-024-01970-0.
» https://doi.org/10.1007/s10840-024-01970-0

[15] ¹⁵ Brasil. Ministério da Saúde. Portaria SECTICS/MS n° 35, de 27 de maio de 2025. Autoriza o repasse referente às ações e serviçospúblicos de saúde por meio de transferências fundo a fundo, em parcela única, para o custeio da Média e Alta Complexidade em Saúde. Diário Oficial da União. 29 May 2025.