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

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.