Mapping and Ablation of atypical atrial flutter with a novel circular pulsed field ablation catheter

Introduction:
Pulsed field ablation (PFA) is a novel means of ablation to treat cardiac arrhythmia. The circular 10-polar bidirectional and size adjustable VARIPULSE™ catheter has been introduced very recently. The catheter is designed for delivery of PFA to the pulmonary veins to achieve pulmonary vein isolation (PVI) in patients suffering from atrial fibrillation (AF). It is fully integrated in the CARTO3 3D mapping system. Even though the catheter is designed primarily for PVI, mapping and ablation of atrial macro-reentrant tachycardia should be feasible.

Methods:
We report a case of a 60-year-old male patient who developed stable atrial tachyarrhythmia during a planned PFA PVI procedure.

Results:
The patient was scheduled for PVI with PFA. After placement of the coronary sinus catheter, atrial fibrillation spontaneously organized to stable tachycardia with 210ms atrial cycle length. Within 14 minutes, an elepctroanatomical map of the left atrium emcompassing 4584 points was recorded. Local activation time (LAT) and coherent mapping showed clockwise perimitral flutter. All pulmonary veins (PV) were isolated with 4 PFA applications at each PV. Taking into account the observed substrate at the anterior wall of the left atrium, we then introduced an anterior line from the left superior pulmonary vein to the mitral annulus by PFA with the circular catheter. The atrial cycle length increased to 230 ms and the CS activation pattern changed, consistent with roof dependent atrial flutter. Further PFA application to connect the superior PVs (roof line) led to termination of the tachycardia into sinus rhythm during ablation.
No further atrial tachyarrhythmias could be induced by atrial burst stimulation. The patient was discharged on the day after the procedure. No complications occurred.

Conclusion:
Mapping and ablation of right and left atrial macro-reentrant tachycardia with the novel circular VARIPULSE™ catheter is feasible. We were able to map and terminate atypical atrial flutter. No complications including no clinically relevant coronary spasms were observed.