Safety and efficacy of very high-power short ablation in superior vena cava isolation in patients with atrial fibrillation
Authors: Fujimoto Y , Okajima S , Hachisuka M , Hagiwara K , Murata H , Aizawa Y , Yodogawa K , Shimizu W , Asai K , Iwasaki Y 
Published: May 2024

Abstract

Backgrounds
The superior vena cava (SVC) plays an important role in non-pulmonary vein (PV) foci to trigger atrial fibrillation (AF) and thus are occasionally isolated. A major complication in SVC isolation is phrenic nerve injury, and a shallower ablation depth might be less likely to cause complications. Recently, very high power short ablation (vHPSD) has been demonstrated to be effective in PV isolation. On the other hand, vHPSD has been reported to have shallower depth than the low-power ablation strategies, suggesting concerns about insufficient ablation in thicker myocardial sites. The vHPSD might be effective and safe in SVC isolation thinner than myocardium, however, the details were not elucidated.

Purpose
This study was aimed to examine the safety and efficacy of vHPSD strategy in SVC isolation, compared retrospectively with low power ablation strategies.

Methods
Patients with AF who were undergoing first-time SVC isolation were included. An activation map was performed from the SVC to the right atrium during sinus rhythm, and a circumferential isolation line was designed by the CARTO system at a height of 1.5cm above the earliest site. The site and extent of capture of the phrenic nerve by pacing on the circumferentially designed ablation line were recorded. The first step was to perform circumferential ablation except for the sites where the phrenic nerve was captured. If the SVC isolation was completed, the procedure was completed. If the isolation was inadequate, the sites of capture of the phrenic nerve were also ablated. Two groups of patients were analyzed: those performing vHPSD (n=27, vHPSD group) with a power of 90 watts for 3 seconds or those using lower-power (n=20, LP group) limited to 20-40 watts.

Results
Forty-seven patients who underwent the initial SVC isolation were evaluated. We analyzed all 351 points in the vHPSD group and all 364 points in the LP group with ablation of SVC. No differences were found in the distance of the SVC circumference on the isolation line (vHPSD: 71±10 vs. LPLD: 71±11mm, p=0.95) or the extent of phrenic nerve capture (12±7 vs. 12±9mm, p=0.82).
All patients in the vHPSD group were successfully isolated first-pass; the first-pass isolation rate tended to be higher than in the LP group (100% vs. 85%, p=0.07).
Differences were observed in temperature rise (49±4 vs. 28±4 degrees, p&lt;0.001) and impedance drop (12±4 vs. 7±5Ω, p&lt;0.001), although there were no differences in the contact force (15±8 vs. 15±7g, p= 0.73). The vHPSD group achieved SVC isolation with a shorter procedure time (9±4 vs. 17±5 min, p&lt;0.001) and fewer ablation points (13±4 vs. 18±4, p&lt;0.001) compared to the LP group. In the vHPSD cases, ATP was administered after isolation, but no dormant conduction was observed. Only in one case in the LP group, transient phrenic nerve injury was observed.

Conclusion
The vHPSD for SVC isolation might be safe and result in shorter procedure time and fewer ablation points.