Received: 30 August 2019 | Revised: 6 November 2019 | Accepted: 10 November 2019

DOI: 10.1111/jce.14285

ORIGINAL ARTICLE

Different tissue thermodynamics between the 40 W and 20 W

radiofrequency power settings under the same ablation
index/lesion size index

Makoto Takemoto MD1 | Mitsuru Takami MD, PhD1 | Koji Fukuzawa MD, PhD2 |
Kunihiko Kiuchi MD, PhD2 | Jun Kurose MD, PhD1 | Hideya Suehiro MD1 |
Yuichi Nagamatsu MD, PhD1 | Tomomi Akita MD1 | Toshihiro Nakamura MD1 |
Jun Sakai MD1 | Atsusuke Yatomi MD1 | Ken‐ichi Hirata MD, PhD2

1
Division of Cardiovascular Medicine,
Department of Internal Medicine, Kobe
University Graduate School of Medicine,
Kobe, Japan
2 predicting the ablation lesion quality, however, collateral damage is still a concern.
Section of Arrhythmia, Division of
Cardiovascular Medicine, Department of
Internal Medicine, Kobe University Graduate
School of Medicine, Kobe, Japan
Correspondence
Mitsuru Takami, 7‐5‐2 Kusunoki‐cho, Chuo‐ku,
Kobe, Hyogo 650‐0017, Japan.
Email: mitsuru_takamin@yahoo.co.jp
Disclosures: None.
Abstract
Introduction: The ablation index (AI) and lesion size index (LSI) are novel markers for
This study aimed to compare the lesion characteristics and tissue temperature profiles
between 20 W (20 Ws) and 40 W (40 Ws) ablation settings under the same AI and LSI.
Methods: An ex vivo model consisting of swine myocardium (5‐6 mm thickness) in a
circulating, warmed saline bath was used. Twenty‐one tissue temperature electrodes
were used. Radiofrequency applications with different power settings were performed
with a 10 to 12 g contact force until the AI and LSI reached 350 and 4.5, respectively.
Results: A total of 120 radiofrequency (RF) applications and 2520 tissue temperature
profiles were analyzed. The speed of the tissue temperature rise with 40 Ws was
significantly faster than that with 20 Ws. However, the maximum tissue temperature
did not significantly differ between 20 and 40 Ws with the same AI (44.6°C ± 3.9°C
vs 45.1°C ± 6.4°C, P = .73), and was significantly lower for 40 Ws with the same LSI
(42.8°C ± 3.4°C vs 40.0°C ± 3.4°C, P = .003). For both the AI and LSI, the number of
electrodes exhibiting high temperatures (≥39°C) was significantly larger and the
duration of high tissue temperatures was significantly longer with 20 Ws. The thermal
latency with 40 Ws was greater.
Conclusions: Although the targeted AI and LSI were the same for both 20 and 40 Ws,
the tissue temperature profiles differed greatly depending on the RF power setting. A
high power setting based on the AI and LSI may reduce the collateral thermal damage.

KEYWORDS
ablation index, catheter ablation, lesion size index, tissue thermodynamics

1 | INTRODUCTION reconduction of the PVs, however, an excessive contact force and

overheating of the tissue can cause steam pops, cardiac perforations,
Pulmonary vein isolation (PVI) is a cornerstone of radiofrequency and collateral damage. Low power long duration RF settings
(RF) catheter ablation of atrial fibrillation. Transmural and contin- (20‐25 W × 20‐30 seconds) have been used for the posterior wall of
uous ablation lesions are essential factors for preventing the left atrium (LA) especially in areas adjacent to the esophagus.

196 | © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jce J Cardiovasc Electrophysiol. 2020;31:196–204.

TAKEMOTO ET AL.
However, esophageal complications such as periesophageal vagal
nerve injury and atrio‐esophageal fistulae due to conduction of the
RF energy remain unsolved.1 Recently, the CARTO VISITAG Module
with the ablation index (AI) and EnSite NavX contact force module
with the lesion size index (LSI) have been developed as markers of
the ablation lesion size, which utilizes the power, time, and contact
force. The AI and LSI have been reported to be superior for
predicting the lesion size than the force time integral.2,3 Several
4,5
clinical studies have shown the utility of the AI/LSI during the PVI.
Theoretically, a similar ablation lesion size can be created under the
same RF index (AI or LSI) even though the RF power settings differ
(high and low power). However, the impact of different power
settings on the tissue temperature profiles under the same RF index
has not been studied. The aim of this study was to evaluate the tissue
thermodynamics with different RF power settings under the same AI
or same LSI, and to find an adequate ablation setting to reduce the
thermal injury to the adjacent tissue and organs.
2 | METHODS
An ex vivo study was performed using swine myocardium in a
circulating, warmed saline bath (36.0‐37.0°C) (Figure 1A). The swine
myocardium used in this study was commercially obtained. In the
present study, we tried to replicate the distance from the tip of
the ablation catheter on the LA posterior wall to the esophageal
temperature probe during the ablation procedure in the human body.
The wall thickness of the posterior wall of the LA is 2.2 ± 0.9 mm and
the anterior wall thickness of the esophagus is 3.6 ± 1.7 mm in
humans.6 Therefore, the swine myocardium tissue (endocardium) was
sliced to a 5 to 6 mm thickness. Three temperature probes
(Sensitherm, Abbott, St. Paul, MN) were placed under the myocardial
tissue side by side (Figure 1B). Each temperature probe had seven
electrodes, therefore, 21 tissue temperature point profiles could be
F I G U R E 1 Ex vivo model. A, An ex vivo model using swine myocardium in a circulating, warmed saline bath (36.0°C‐37.0°C). The
myocardium was sliced into 5‐ to 6‐mm thicknesses. The temperature probe was set under the myocardium at a site opposite the ablation
catheter. B, Temperature electrode arrangement. A total of 21 temperature electrodes were placed under the myocardium
| 197
monitored simultaneously. The RF applications were performed using
a ThermoCool SmartTouch SF catheter with the SMARTABLATE RF
Generator (Biosense Webster Inc., Diamond Bar, CA) and Tacti-
Cath SE catheter with the Ampere RF Generator (Abbott, St. Paul,
MN) with a 10 to 12 g contact force until the AI or LSI reached the
target value. The target AI value was 350 and the target LSI value
was 4.5, which are used for the LA posterior wall in clinical
practice.2,4 The angle of the ablation catheter was kept at 45° from
the tissue. The catheter was released from the tissue when the
targeted AI/LSI was reached. Two different power settings (20 and
40 W) were examined using each ablation catheter. The irrigation
flow rate was 8 mL/min during 20 W ablation applications and 15 mL/
min during 40 W ablation applications with the ThermoCool, and
17 mL/min during 20 W ablation applications and 30 mL/min during
40 W ablation applications with the Tacticath. A high tissue
temperature was defined a tissue temperature of ≥39°C in the
present study. Continuous tissue temperatures were recorded
from the start of the RF application until the tissue temperature
dropped down below 39°C after the RF application was stopped.
The tissue temperature profiles and ablation lesion dimensions with
each RF application were recorded and analyzed. The ablation
lesion edge was decided by visually analyzing the tissue sections.
The dimensions were analyzed using a micrometer. Some tissue
sections were also analyzed microscopically to confirm the ablation
lesion edge.
2.1 | Statistical analysis
Continuous variables are presented as the mean ± SD. Comparisons
between the two groups (20 vs 40 W) for each catheter were made
by an unpaired t test. A value of P < .05 was considered statistically
significant. All statistics were performed using SPSS for Windows
ver22.0 software (SPSS, Chicago, IL).
198 | TAKEMOTO ET AL.

3 | RES U LTS
A total of 120 RF applications (based on the AI: n = 60 [20 W: n = 30,
40 W: n = 30], based on the LSI: n = 60 [20 W: n = 30, 40 W: n = 30])
were delivered. A total of 120 ablation lesions and 2520 temperature
profiles were analyzed.
3.1 | RF applications based on the AI (AI: 350)
3.1.1 | Tissue thermodynamics
Figure 2 shows the representative tissue temperature changes during/
after the RF applications based on the same AI. A rapid temperature
rise was seen with the 40 W ablation applications just after the RF
application was started. In contrast, the 20 W ablation applications
exhibited a slower tissue temperature rise. After stopping the RF
application, the tissue temperature still rose for a while (thermal
latency). Figure 3 shows the schema of the highest tissue temperature
distribution of the nine electrodes close to the ablation catheter. The
high tissue temperatures during the 20 W ablation applications were
more widely distributed than those during the 40 W ablation
applications. Table 1 shows the comparison of the tissue temperature
profiles between the 20 and 40 W ablation applications. The impedance
drop during the RF applications was not significant, however, the
ablation time to reach the target AI with the 40 W ablation applications
was significantly shorter than that with the 20 W ablation applications
(31.1 vs 11.6 seconds, P < .0001). The speed of the temperature rise
with the 40 W ablation applications was significantly faster. The
maximum tissue temperature did not significantly differ between the
20 and 40 W ablation applications. The thermal latency (ΔT [°C]) was
significantly larger and duration significantly longer with the 40 W
ablation applications. The duration of the high tissue temperatures
(≥39°C) was significantly longer with the 20 W ablation applications.
The number of electrodes that exhibited high temperatures (≥39°C)
was significantly greater with the 20 W ablation applications.

F I G U R E 2 Tissue temperature changes during and after the RF applications with 20 and 40 W ablation applications (targeted AI; 350). The
electrode placed under the tip of the ablation catheter (number 5) exhibits the highest tissue temperature. A, 20 W ablation. The speed of the
temperature increase was slow. After stopping the RF application, thermal latency was observed (ΔT: 0.3°C, Δt: 3.2 seconds). Three electrodes
exhibited high temperatures (≥39°C). B, 40 W ablation. The speed of the temperature increase was fast. After stopping the RF application,
thermal latency was observed (ΔT: 1.2°C, Δt: 2.2 seconds). Two electrodes exhibited high temperatures. AI, ablation index; RF, radiofrequency
TAKEMOTO ET AL. | 199

F I G U R E 3 The schema of the highest tissue temperature distribution among the nine electrodes close to the ablation catheter during the 30
RF applications based on the AI. Each small colored dot means the highest temperature recorded by the electrode during each RF application.
The highest temperatures were classified every 1°C as different colors. The deep red, red, and orange dots, which indicate high tissue
temperatures (≥39°C), are more widely distributed with the 20 W ablation applications. AI, ablation index; RF, radiofrequency

3.1.2 | Lesion geometry
Figure 4A,B shows the ablation lesion dimensions with the 20 and
40 W ablation applications under the same AI. The surface lesion
diameter tended to be larger with the 40 W ablation applications,
however, the lesion diameter and depth did not significantly differ
between the 20 and 40 W ablation applications.
3.2 | RF applications based on the LSI (LSI: 4.5)
P < .0001). The speed of the temperature rise with the 40 W ablation
applications was significantly faster, however, the maximum tissue
temperature was significantly lower with 40 W applications. The
thermal latency (ΔT [⁰C]) was significantly larger and the duration of
the thermal latency (Δt [sec]) was significantly longer with the 40 W
ablation applications. The duration of the high tissue temperatures
(≥39°C) was significantly longer, and the number of electrodes that
exhibited high temperatures was significantly greater with the 20 W
ablation applications.

3.2.1 | Tissue thermodynamics 3.2.2 | Lesion geometry

Figure 5 shows the representative tissue temperature changes based
on the same LSI.
The 40 W ablation applications exhibited a rapid temperature rise
just after the RF application. Thermal latency was observed after
stopping the RF application. Figure 6 shows the schema of the high
tissue temperature distribution. The high tissue temperatures with
the 20 W ablation applications were more widely distributed than
those with the 40 W ablation applications. Table 2 shows the
comparison of the tissue temperature profiles with the 20 and 40 W
ablation applications. The mean duration to reach the targeted LSI
with the 20 W ablation applications was about five times longer than
that with the 40 W ablation applications (45.2 vs 9.6 seconds,
When the target LSI was 4.5, the surface lesion diameter, maximum
lesion diameter, and lesion depth with the 20 W ablation applications
were significantly greater than those with the 40 W applications
(Figure 7A,B). Figure 8 shows the histological changes of the ablation
lesion.
4 | D I S C U SS I O N
Multiple tissue temperatures were monitored simultaneously over
a wide area, which provided us information on the vertical and
horizontal spread of the thermal energy. The major findings of the
200 | TAKEMOTO ET AL.

T A B L E 1 Summary of the ablation and temperature profiles based between the 20 and 40 W ablation applications. (b) When the RF
on the AI applications were delivered under the same LSI (LSI: 4.5), the
AI 350 maximum tissue temperature was significantly lower with the 40 W

20 W 40 W ablation applications. The duration of the high tissue temperature

(n = 30) (n = 30) P value was significantly longer and distribution significantly greater with the

Impedance drop, Ω 15.4 ± 4.1 15.3 ± 3.9 .91

20 W ablation applications. The lesion size was significantly larger
with the 20 W ablation applications. (c) With both the AI and LSI, the
Time to reach the targeted 31.1 ± 2.2 11.6 ± 1.4 <.001
AI/LSI, s thermal latency was significantly greater and duration significantly

Speed of the tissue 0.24 ± 0.12 0.69 ± 0.52 <.001

longer with the 40 W ablation applications than those with the 20 W
temperature rise, °C/sa ablation applications.
Maximum tissue 44.6 ± 3.9 45.1 ± 6.4 .73
temperature (°C)
Thermal latency (ΔT) (°C)b 0.65 ± 1.07 0.84 ± 0.76 .04 4.1 | Tissue thermodynamics
c
Thermal latency (Δt), s 0.3 ± 2.8 2.2 ± 2.6 .006
Duration of high tissue 39 ± 12 24 ± 14 <.001
Recently, experimental data on the very high power (70‐90 W) short
temperature (≥39°C), sd duration ablation using a specific ablation catheter has been
No. of electrodes showing 3.4 ± 1.4 2.5 ± 1.2 .01 reported.7,8 However, this new ablation device has not been widely
high temperature (≥39°C) used in clinical practice thus far. Instead, catheter ablation to perform
Mean ± SD a PVI using a conventional RF catheter with a relatively high power

Abbreviations: AI, ablation index; LSI, lesion size index; RF, radiofrequency.
a
The speed of the tissue temperature rise from the start of the ablation to
reaching the targeted LSI.
b
The temperature rise after stopping the RF application.
c
The duration of the temperature rise after stopping the RF application.
d
The duration of any tissue electrode exhibiting a temperature over 39°C
during each RF application.
present study were that (a) when the RF application was delivered
under the same AI (AI: 350), the maximum tissue temperature was
comparable, however, the duration of a high tissue temperature was
significantly longer and distribution significantly greater with the
20 W ablation applications. The lesion size did not significant differ
(40‐50 W) short duration setting has been performed.9,10 One of the
primary concerns of high power ablation is collateral damage,
especially esophageal injury including atrio‐esophageal fistulae.11 A
low power (20‐25 W) long duration (20‐30 seconds) ablation using an
esophageal temperature monitoring system has usually been
performed for the LA posterior wall. RF applications can be stopped
when the monitored esophageal temperature exceeds a certain
temperature (ie, 39°C). However, the current esophageal tempera-
ture monitoring devices can monitor only a limited area of the
esophagus. Therefore, there is the possibility that we could under-
estimate real esophageal temperature rises during the RF applica-
tions on the LA posterior wall. The present study revealed significant

F I G U R E 4 Ablation lesion geometry. A, Cross section of representative lesions in 20 and 40 W ablation under the same AI (AI: 350). B,
Comparison of the lesion dimension and depth between the 20 and 40 W ablation applications. AI, ablation index
TAKEMOTO ET AL. | 201

F I G U R E 5 Tissue temperature changes during and after the RF applications with 20 and 40 W (targeted LSI; 4.5). The electrode placed
under the tip of the ablation catheter (number 5) exhibits the highest tissue temperature. A, 20 W ablation. The speed of the temperature
increase was slow. After stopping the RF application, thermal latency was observed (ΔT: 0.2°C, Δt: 1.8 seconds). Five electrodes exhibited high
temperatures (≥39°C). B, 40 W ablation. The speed of the temperature increase was fast. After stopping the RF application, thermal latency was
observed (ΔT: 1.0°C, Δt: 6.0 seconds). Three electrodes exhibited high temperatures. LSI, lesion size index; RF, radiofrequency

differences in the tissue thermodynamics between 20 and 40 W
ablation applications.
Previous preclinical studies showed the tissue temperature
profiles with a high power short duration ablation,8,12 which were
useful to learn the biophysics of the high power ablation. The present
study additionally provided practical information for use in the
clinical situation. When we deliver high power RF applications in the
atrium, we need to be sure to create adequate lesions to achieve a
PV isolation, and not to overheat the tissue, to avoid any
complications. The AI and LSI have been established as parameters
for evaluating the lesion quality and are widely accepted in PV
isolation.2-5 The knowledge of the tissue thermodynamics with
different power settings based on the AI/LSI would be important to
create adequate lesions and to determine the RF power settings for
use in the clinical situation. In addition, we revealed the horizontal
spread of the thermal conduction from the ablation catheter
(Figures 3 and 6). Previous studies showed the tissue temperature
profiles in the tissue below the ablation catheter (vertical direc-
8,12
tion). However, the thermal conduction in the horizontal direction
would also be important to avoid esophageal injury because the
esophagus in humans can extend up to 3 cm laterally. The mechanism
of the esophageal thermal injury caused by RF applications is not
fully understood, however, not only the maximum esophageal
temperature, but also the heating area and heating duration in the
esophagus would have a risk of esophageal injury.
Tissue heating can be separated into direct resistive heating and
conductive heating. Electrical current, which flows through a material
with a certain electrical resistance, dissipates the power in the
material, which generates resistive heating.13 Therefore, high power
RF applications can produce greater resistive heating. However, the
current density decreases with the distance from the electrode. For
the tissue at a greater distance from the electrode, tissue heating is
mainly caused by conductive heating. A low power and longer
duration ablation could generate more conductive heating over
larger areas, which would cause thermal injury to the tissue and
organs at a greater distance from the ablation catheter.
Wittkamph et al14 reported that thermal latency of the tissue was
caused by the different response times between resistive heating and
202 | TAKEMOTO ET AL.

F I G U R E 6 Schema of the highest tissue temperature distribution among the nine electrodes close to the ablation catheter during 30 RF
applications based on the LSI. Each small colored dot means the highest temperature recorded by the electrode during each RF application. The
highest temperatures were classified every 1°C as different colors. The deep red, red, and orange dots, which indicate high tissue temperatures
(≥39°C), are more widely distributed with the 20 W ablation applications. LSI, lesion size index; RF, radiofrequency

conductive heating. Just after the RF application starts, a large

T A B L E 2 Summary of the ablation and temperature profiles based temperature gradient near the ablation electrode exists. Therefore, a
on the LSI surplus of heat that continues to flow to the surrounding tissue even
LSI 4.5 after the RF application stops. This thermal latency may result in
20 W 40 W lesion growth after high power short RF applications, and this can
(n = 30) (n = 30) P value explain why the lesion size was comparable between the 20 W long
Impedance drop, Ω 13.5 ± 5.9 13.8 ± 4.7 .27 duration and 40 W short duration ablation applications even when

Time to reach the targeted 45.2 ± 7.8 9.6 ± 1.8 <.0001 the tissue temperature profiles significantly differed.
LSI, s The data in the present study may also support the results of
Speed of the tissue 0.12 ± 0.07 0.24 ± 0.25 .021 recent clinical studies that showed the efficacy and low esophageal
temperature rise, °C/sa complication rates with relatively high power short duration ablation
Maximum tissue 42.8 ± 3.4 40.0 ± 3.4 .003 applications.9,15
temperature (°C)
Thermal latency (ΔT) (°C)b 0.11 ± 0.10 0.31 ± 0.30 .002
Thermal latency (Δt), sc 1.0 ± 5.1 4.9 ± 7.2 .019 4.2 | Lesion geometry
Duration of high tissue 77 ± 27 27 ± 34 <.0001
temperature (≥39°C), sd For both the AI and LSI, the 40 W ablation applications tended to create
No. of electrodes showing 4.4 ± 1.9 1.6 ± 2.2 <.0001 larger surface lesion diameters. Bourier et al16 reported the difference
high temperature (≥39°C) in the lesion geometry with various power settings (30‐80 W). They
Mean ± SD found that standard (30 W) as well as high power (50‐80 W) short
Abbreviations: LSI, lesion size index; RF, radiofrequency. duration RF applications resulted in similar lesion volumes, however,
a
The speed of the tissue temperature rise from the start of the ablation to the lesion surface diameter was significantly larger in the high power
reaching the targeted LSI. group. The ablation lesions were mainly created by conductive heating
b
The temperature rise after stopping the RF application.
c with the low power (20 W) longer duration ablation applications. The
The duration of the temperature rise after stopping the RF application.
d
The duration of any tissue electrode exhibiting a temperature over 39°C convective cooling by the blood flow and catheter irrigation flow can
during each RF application. also affect the lesion formation,13 which would weaken the conductive
TAKEMOTO ET AL.
F I G U R E 7 Ablation lesion geometry. A, Cross section of representative lesions in 20 and 40 W ablation under the same LSI (LSI: 4.5). B,
Comparison of the lesion dimension and depth between the 20 and 40 W ablation applications. LSI, lesion size index
heating on the tissue surface. In contrast, high power (40 W) ablation
can quickly generate stronger resistive heating, which could create a
wider surface lesion area.
There would be several reasons for the significant lesion differences
between 20 and 40 W ablation applications with the same LSI even
though the lesion size was similar with the same AI. First, the mean
duration to reach the targeted LSI (LSI: 4.5) with the 20 W ablation
applications was about five times longer than that with the 40 W
ablation applications (45.2 vs 9.6 seconds). A longer duration ablation
resulted in stronger conductive heating and larger lesions with the
20 W ablation applications under the LSI. In contrast, the mean duration
to reach the targeted AI with the 20 W ablation applications was three
times longer than that with the 40 W applications (31.1 vs 11.6 seconds).
Both the AI and LSI are markers of the lesion size, however, the
formulas of the indices are very different. This difference would affect
the ablation duration between the 20 and 40 W ablation applications.
Second, the RF generators utilized with each catheter would affect the
lesion formation. The time to reach the targeted power (ramp‐up time)
was within 1 second in a SMARTABLATE RF Generator (AI). However,
the ramp‐up time was 2 seconds with the Ampere RF Generator (LSI).
With the high power short duration setting, the shorter ramp‐up time
with the SMARTABLATE RF Generator (AI) would create comparable
lesions with a low power longer duration ablation.
F I G U R E 8 Microscopic findings in the
ablation lesion. The ablation lesions in
20 and 40 W under the same LSI (4.5) were
sectioned for staining with Masson
trichrome stains. The white dotted line
indicates the ablation lesion edge. LSI,
lesion size index
| 203
4.3 | Clinical implications
In human hearts, the stability of the ablation catheter is affected by
the motion of the heart beats and respiratory motion. Therefore, a
relatively high power (40 W) ablation based on the AI/LSI could be
useful for creating ablation lesions in the atrium where the ablation
catheter stability cannot be maintained for a long duration.
Considering the wall thickness of the posterior wall of the LA,
relatively high power RF applications based on the AI/LSI would be
one option to create adequate ablation lesions and decrease the
thermal injury to the adjacent tissue and organs. At the same time,
we should keep in mind the rapid rise in the tissue temperature and
thermal latency with high power ablation. The RF application should
be stopped as soon as the target AI/LSI is reached, otherwise a high
power ablation could cause overheating of the myocardium and
thermal injury to the adjacent tissues.
4.4 | Limitations
The environment of the ex vivo experimental model used in the
present study differed from that of the human body, which might
have affected the results. The use of dead swine myocardium
204 | TAKEMOTO
(without blood tissue perfusion) is associated with a smaller heat sink
and would result in a greater lesion size. Different tissue components
and the muscle fiber orientation would affect the thermal conduc-
tion. The beating motion of the heart and respiratory motion could
not be replicated in the present study. The distance from the ablation
catheter to the esophagus in patients is quite variable and can
depend upon the variable thickness of the atrial myocardium as well
as the extent of epicardial fat. We applied the RF applications with a
catheter position set at 45° from the tissue, and the contact force
was 10 to 12 g. The effects of the tissue thermodynamics with other
catheter positions (perpendicular, parallel) and different contact
forces were not examined.
5 | CONC LU SION
Although the AI and LSI were the same, the tissue temperature
profiles greatly differed depending on the RF power setting.
Relatively high power RF (40 W) applications based on the AI or
LSI would create comparable ablation lesions to low power RF (20 W)
long duration ablation applications and would reduce the thermal
damage to the adjacent tissue and organs.
A C K N O W L E D GM E N T
The authors would like to thank Dr. Naofumi Yoshida for technical
assistance with the histological analysis and also thank Mr. John
Martin for editing the language in the manuscript.
CO NFLICT OF I NTERE STS
The Section of Arrhythmia is supported by an endowment from
Medtronic JAPAN and Abbott JAPAN. Dr. Hirata chairs the Section,
Dr. Fukuzawa and Dr. Kiuchi belong to the Section. However, all
authors report no conflict of interest for this manuscript contents.
OR CID
Mitsuru Takami http://orcid.org/0000-0002-1768-802X
Kunihiko Kiuchi http://orcid.org/0000-0002-9305-4854
Toshihiro Nakamura http://orcid.org/0000-0003-0521-3008
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How to cite this article: Takemoto M, Takami M, Fukuzawa K,
et al. Different tissue thermodynamics between the 40 W and
20 W radiofrequency power settings under the same ablation
index/lesion size index. J Cardiovasc Electrophysiol.
2020;31:196–204. https://doi.org/10.1111/jce.14285