Validity and safety of HP strategy
Recent clinical studies revealed the efficacy and safety of HPSD-PVI over conventional PVI at normal power and duration,[8-10] where RF time and energy could be reduced.[2, 3] The result shown here concurred with that of previous reports with total RF time of 10 min and RF energy of 29 kJ for PVI.[2, 11]
Theoretically, HPSD-PVI could lessen collateral damage with a shallow and wide lesion creation due to resistive heating.[12, 13] Clinically, Winkle et al have recently demonstrated the extremely low complication rate using HPSD-PVI, where a smaller number of atrio-esophageal fistula was observed compared to the conventional strategy.[14] Similarly, by assessing esophageal thermal injury after HPSD-PVI by late gadolinium enhancement magnetic resonance imaging within 24 hours post-procedure, Baher et al concluded that the distribution and severity of esophageal damage was similar between HPSD-PVI and low power long duration groups.[15] These data highlighted the safeness of HPSD-PVI over conventional strategy. In the present study, only 1 patient with an enlarged LA had experienced acute right phrenic nerve injury after right-sided PVI, although this partially recovered within half a year. Subsequently, a 10-mA stimulation test was routinely performed at the right superior PV antrum to avoid phrenic nerve injury. In patients with breathing disorder, deep sedation could hinder HPSD-PVI due to unstable catheter contact. Therefore, moderate anesthesia with dexmedetomidine could keep optimal condition without evoking breathing disorder in such cases. Similarly, controlled tidal volume using mechanical ventilator could allow for HPSD-PVI even in patients under general anesthesia.