Comparing High Power Short Duration Ablation and Pulsed Field Ablation—Which Approach for Which Patient?

Interview With Andrea Natale, MD, FACC

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Interview by Jodie Elrod

Watch as Andrea Natale, MD, FACC, from Texas Cardiac Arrhythmia Institute at St. David's Medical Center, discusses his Western AF 2025 presentation.

Tell us about your presentation at the Western AFib Symposium 2025. 

My name is Andrea Natale. I am an electrophysiologist in Austin, Texas, and the Executive Medical Director of the Texas Cardiac Arrhythmia Institute at St David’s Medical Center. This presentation was about choosing between high power short duration ablation versus pulsed field ablation, which is the new energy source. Obviously, we have a long history with high power short duration ablation and we've been working on optimizing that approach for the last 20+ years. So, we had been using that approach to the point that we were very happy. But pulsed field ablation is really making a difference, and I think it is time to seriously think about switching. 

What are the take-home messages you would like viewers to leave with?

I think the problem with high power short duration ablation is that it's still a very operator-dependent approach in terms of what power they choose and for how long they use it. We are trying to look at those differences and come up with a recipe that makes sense. But this is not universally accepted or used anywhere. Some of the latest technology in radiofrequency ablation is less operative dependent because the system adjusts the power based on tissue temperature. However, we still have to deal with the potential complications of thermal energy, which is pulmonary vein stenosis, esophageal fistula, and phrenic nerve paralysis. So, the advantage of pulsed field ablation is that all that goes away. From a safety point of view and patient perspective, it's spectacular. The issue with pulsed field ablation is that we're using now the first-generation tool. So, in certain areas, some of the early devices are not necessarily as effective as maybe high power short duration ablation can be, but this is changing very rapidly. My feeling is that just because of the safety, we should embrace pulsed field ablation, and very soon, with the next-generation tool and some of the tools that are already available to us, I think we can address those more difficult areas. 

The transcripts have been edited for clarity and length.