Organization of atrial flutter during pulse field ablation for atrial fibrillation

Pulse Field Ablation (PFA) has been acknowledged as an effective and safe tool for ablation of Atrial Fibrillation (AF). It is known that during AF ablation, the arrhythmia may organize into atrial flutter. The left atrial posterior wall is identified as a critical source of non-Pulmonary Vein (PV) triggers that facilitate maintenance of atrial fibrillation.

The purpose of this study is to investigate the phenomenon of atrial flutter organization from AF during the application of PFA.

This prospective multicentric study encompasses 117 consecutive patients with persistent AF across American and European institutions, undergoing first time catheter ablation. All receive isolation of the Pulmonary Veins (PV) plus Posterior Wall (PW) isolation. The PW isolation procedure targeted the standard area between the PVs and extended to the area demarcated by the line connecting the inferior borders of the inferior PV-encircling lesions to the coronary sinus defined lower part of PW (Fig. 1). The study documented the specific locations where AF organized into atrial flutter with a stable cycle length during PFA.

Organization of AF to atrial flutter during PFA was observed in 72 (61.5%) patients. Analysis of the organization of flutter revealed that in 41 (56.9%) of these cases, flutter began while ablating the lower part of the PW. Moreover, 9 (12.5%) initiated at one of the PVs, and 22 (30.5%) during the ablation of the posterior wall. Notably, the flutter was described as perimitral flutter in 33 (45.8%), as typical flutter in 24 (33.3%), and as roof-dependent flutter in 15 (20.8%) of cases.

The findings underscore that during PFA for AF, there is a pronounced tendency for the arrhythmia to organize into atrial flutter, particularly during the ablation of the lower posterior wall. Notably ablation in the left atrium organized AF in typical atrial flutter at a considerable rate.

Ablation on lower part of PW