Muthu, Padmapriya

BACKGROUND: Cavotricuspid isthmus (CTI) ablation is frequently performed either as a standalone procedure or in combination with pulmonary vein isolation. With the rapid adoption of pulsed field ablation for atrial fibrillation, it is essential to delineate the utility of this modality in treating CTI-dependent atrial flutter (AFL). This study aims to evaluate the procedural and clinical outcomes of CTI ablation using pulsed field energy. METHODS: We conducted a retrospective analysis of consecutive patients who underwent pulsed field ablation for CTI-dependent AFL between January 2024 and March 2025. The primary end points were acute procedural success, periprocedural complications, and CTI-dependent AFL recurrence during follow-up. RESULTS: A total of 132 patients underwent CTI nonthermal ablation. The median age was 69.5 years, and 27.3% were female. The Farawave catheter was used in 93.9% of cases, PulseSelect in 4.5%, and Sphere-9 in 1.5%. Acute block was achieved in 99.2% of patients, although 8 required adjunctive radiofrequency ablation to complete the line. Periprocedural complications included transient ST-segment elevation in 2 patients and transient conduction disturbances in 3. During a median follow-up of 114 days (n=131), 5 patients (3.8%) experienced recurrence of typical AFL. The 6-month typical AFL-free survival estimate was 93.6%. CONCLUSIONS: Pulsed field ablation appears to be a feasible and effective strategy for CTI-dependent AFL. However, anatomic variability may limit its universal applicability with current catheter designs. Although acute procedural success is high, the long-term durability of the CTI block and its comparative efficacy versus conventional thermal ablation remain areas requiring further investigation.

ABSTRACT Cavotricuspid isthmus ablation (CTI) is a first‐line therapy in patients with typical atrial flutter. With the advent of pulsed field (PF) as a new energy source, we sought to evaluate the use of PF for CTI ablation. A systematic literature search was conducted on the use of PF for CTI‐flutter up to December 2024. A meta‐analysis was performed for studies reporting pooled data, while individual case reports were reviewed and summarized. The mean number of PF applications, acute success rate, and prevalence of coronary vasospasm were evaluated. Eleven studies with pooled data from 155 patients were included. All patients had an acute block of the CTI. The mean number of PFA applications was 7.78 (95% CI 6.53–9.48). The incidence of ST‐elevation was 0.04% (95% CI 0–2.23%). Subclinical vasospasm was documented in 45% (95% CI 32%–59%) of patients who underwent periprocedural coronary angiography. Prophylactic use of nitrates showed a trend toward reducing the incidence of subclinical vasospasm (RR 0.24, 95% CI 0.06–1.06, p = 0.059). Twelve cases with patient‐level data were included; six reported complications, including ST elevation and conduction disturbances. PFA for CTI flutter demonstrates high acute success; however, evidence regarding the durability of the block is limited. Clinical vasospasm with ST segment elevation is uncommon but can lead to life‐threatening complications. The incidence of subclinical vasospasm is high, and nitrates tend toward reducing this phenomenon. To date, the role of PFA for this condition appears to be limited.

Background: Cavotricuspid isthmus ablation (CTI) is a first line therapy in patients with typical atrial flutter. With the advent of Pulsed Field (PF) as a new energy source, we sought to evaluate the use of PF for CTI ablation. A systematic literature search was conducted on the use of PF for CTI-flutter up to December 2024. A meta-analysis was performed for studies reporting pooled data, while a patient-level summary was done for reports with available individual data. The mean number of PF applications, acute success rate, and prevalence of coronary vasospasm were evaluated. Results: Eleven studies with pooled data from 155 patients were included. All patients had an acute block of the CTI. The mean number of PFA applications was 7.78 (95% CI 6.53–9.48). The incidence of ST-elevation was 0.04% (95% CI 0-2.23%). Subclinical vasospasm was documented in 45% (95% CI 32%–59%) of patients who underwent periprocedural coronary angiography. Prophylactic use of nitrates showed a trend toward reducing the incidence of subclinical vasospasm (RR 0.24, 95% CI 0.06–1.06, p=0.059). Twelve cases with patient-level data were included; six reported complications, including ST elevation and conduction disturbances. Conclusion: PFA for CTI flutter demonstrates high acute success; however, evidence regarding the durability of the block is limited. Clinical vasospasm with ST segment elevation is uncommon but can lead to life-threatening complications. The incidence of subclinical vasospasm is high, and nitrates trend toward reducing this phenomenon. To date, the role of PFA for this condition appears to be limited.

ABSTRACT Introduction Atrial fibrillation (AF) is the most common arrhythmia, and atrioventricular (AV) node ablation with pacemaker implantation is a therapeutic option for refractory cases. However, AV node ablation in patients with bioprosthetic tricuspid valves poses technical challenges. Methods An 84‐year‐old male with an EVOQUE transcatheter tricuspid valve replacement underwent AV node ablation (AVNA) under intracardiac echocardiography (ICE) guidance. Results Successful AV block was achieved with precise catheter positioning, improving the patient's symptoms and ventricular rate control. Conclusion This case demonstrates the feasibility of AVNA in patients with tricuspid bioprostheses, demonstrating feasibility with ICE guidance.

This is the first reported case of atrioventricular node ablation (AVNA) in a patient with an EVOQUE transcatheter tricuspid valve, performed for refractory atrial fibrillation with uncontrolled ventricular rates. This case highlights the feasibility and importance of advanced imaging techniques in managing arrhythmias in patients with bioprosthetic valves, offering insights into expanding therapeutic options for complex cardiovascular conditions.