A Trial of High Power-Short Duration Versus Standard Power-Long Duration Radiofrequency Ablation for Treatment of Atrial Fibrillation

Study Overview
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Brief Summary
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This study is a prospective, randomized controlled study to compare overall clinical outcomes between High Power Short Duration (HPSD) and standard radiofrequency (RF) ablation settings for Atrial Fibrillation (AF) ablation in the treatment of subjects with paroxysmal or persistent Atrial Fibrillation.

Detailed Description
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Pulmonary vein isolation using radiofrequency (RF) ablation is a widely used treatment strategy for atrial fibrillation. Peri-procedural complications rates are estimated at between 1.5 - 6% with the two most feared complications being stroke and atrial-esophageal fistula. The risk of these complications increases with (1) longer left atrial dwell times with greater potential for clot formation and (2) esophageal heating during delivery of radiofrequency energy. 'High-power short-duration' (HPSD) is an increasingly utilized strategy to decrease procedure duration and minimize the risk of these complications. Potential mechanisms for benefit include: (1) shorter left atrial dwell times due to more efficient lesion delivery (2) rapid, but more controlled, resistive tissue heating, which avoids deeper, passive conductive heating that can reach the esophagus and cause injury. Moreover, HPSD may improve lesion efficacy and durability due to less recover of excitability after ablation. Despite being widely used and several retrospective studies, there have been no prospective randomized trials comparing outcomes between HPSD and standard RF ablation settings. Moreover, the investigators are interested to see if a shorter procedure (less time in the left atrium) is associated with a lower rate of silent cerebral infarctions (which are occasionally seen on MRI brain post RF ablation - their clinical significance is unclear).

Official Title
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SHORT-AF: A Randomized Trial of High Power-Short Duration Versus Standard Power-Long Duration Radiofrequency Ablation for Treatment of Atrial Fibrillation

Conditions
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Atrial Fibrillation, Atrial Fibrillation Paroxysmal, Atrial Fibrillation, Persistent

Intervention / Treatment
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* Procedure: Catheter ablation with Standard RF ablation settings
* Procedure: Catheter ablation with High Power Short Duration RF ablation settings


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male or female ≥18 years of age at their pre-operative visit. Patient is scheduled to have their first AF ablation Paroxysmal or persistent AF Written informed consent (and assent when applicable) obtained from subject or subject's legal representative and ability for subject to comply with the requirements of the study. Exclusion Criteria: Prior AF ablation Stroke or transient ischemic attack (TIA) within the previous 6 months Known esophageal ulcer or gastrointestinal (GI) bleed within prior 6 months Intent to perform adjunctive left atrial ablation, including posterior wall isolation, left atrial appendage isolation, mitral or other linear lesions. Prior rheumatic heart disease or significant mitral stenosis Mechanical mitral valve replacement Long lasting persistent AF > 1 year Severe left ventricular systolic dysfunction, with LV ejection fraction LVEF<35% Prior left atrial appendage (LAA) occlusion device Prior septal occlusion device Pregnancy Pacemaker, defibrillator or any contraindication to MRI

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a multi-center prospective single-blinded randomized controlled trial. Enrollment of 60 subjects undergoing clinically-indicated AF ablation is planned with 1:1 block randomization (standard 'low power' RF settings n=30, HPSD n=30 and allowing for 10 drop-outs / consent withdrawals). Follow-up will be over 12 months.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard Catheter Settings<br>Group 1 - Standard RF ablation settings | Procedure: Catheter ablation with Standard RF ablation settings<br>* Standard RF ablation settings (n=30): Maximum 35W for 20-40 seconds, per operator standard.<br>|
| Experimental: High Power Short Duration (HPSD)<br>Group 2 - High power short duration RF | Procedure: Catheter ablation with High Power Short Duration RF ablation settings<br>* High power short duration RF (n=30): Maximum 50 Watts for 5-15 seconds, per operator standard.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Ablation Duration | RF ablation duration from start of first pulmonary vein isolation lesion to end of last lesion | During Ablation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Maximum esophageal temperature |  | During ablation | 
| Maximum esophageal temperature rise |  | During ablation | 
| Freedom from Atrial Fibrillation | >30 secs using Ziopatch, 1 year off or on previously ineffective antiarrhythmic drugs (AADs) | assessed at 6 and 12 months post-ablation | 
| Freedom from Atrial Fibrillation | >30 secs using Ziopatch, 1 year off previously ineffective antiarrhythmic drugs (AADs) | assessed at 6 and 12 months post-ablation | 
| % pulmonary vein pairs isolated with first encirclement |  | During Ablation | 
| Number of radiofrequency lesions required for isolation/PV |  | During Ablation | 
| Total left atrial radiofrequency (RF) time |  | During Ablation | 
| Total procedure duration |  | During Ablation | 
| Overall complication rate |  | During Ablation and up to 12 month follow up assessment | 
| Pleurisy |  | At 1 week and 1 month assessment | 
| Pericardial effusion>1cm |  | During ablation or up to 30 days post ablation | 
| Pericardial tamponade requiring drainage |  | During ablation or up to 30 days post ablation | 
| Total saline infused |  | During Ablation | 
| Presence of asymptomatic cerebral emboli |  | 1 day post-ablation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Atrial Fibrillation