Pulsed field ablation for CTI-dependent atrial flutter demonstrated high procedural effectiveness, achieving a pooled acute bidirectional block rate of 98.1% (95% CI: 96.8-99.5).
Meta-Analysis
Does pulsed field ablation effectively and safely achieve bidirectional block in adult patients with cavotricuspid isthmus-dependent atrial flutter?
Pulsed field ablation demonstrates high procedural effectiveness (98.1% acute bidirectional block) and good short-term durability for CTI-dependent atrial flutter, though coronary vasospasm is frequently observed.
Background Cavotricuspid isthmus (CTI) dependent atrial flutter (AFL) is conventionally managed using radiofrequency catheter ablation. Pulsed field ablation (PFA) is an emerging non-thermal ablation technique using electroporation to create lesions across CTI. While it is well established for pulmonary vein isolation in atrial fibrillation, its effectiveness in CTI-dependent atrial flutter remains insufficiently characterized. Methods This meta-analysis followed PRISMA guidelines, with a comprehensive search of databases through December 2025. Eligible studies included adult patients undergoing CTI ablation using PFA and reporting CTI-specific outcomes. Pooled event rates and means with 95% confidence intervals (CIs) were estimated using a random-effects model, with heterogeneity evaluated using the I2 statistic. Results Eighteen studies were included. The pooled rate of acute bidirectional CTI block was 98.1% (95% CI: 96.8–99.5; I2 = 47.1%). Acute CTI reconduction occurred in 6.9%. During follow-up, recurrence of typical AFL was 2.0%, while freedom from CTI-dependent AFL was 97.2% (I2= 0%) and recurrence of any atrial tachyarrhythmia was observed in 4.2%. Safety outcomes showed low rates of coronary artery stenosis (0.5%), transient ST-segment elevation (0.8%), conduction disturbances (0.5%), and transient atrioventricular block (1.7%). Coronary vasospasm was more frequently reported (33.4%) with substantial heterogeneity. CTI ablation time was 7.9 min, and mean number of PFA applications was 10.6. Conclusion PFA demonstrates high procedural effectiveness in CTI-dependent atrial flutter, with good short-term durability and low complication rates. Despite predominantly observational data, PFA appears to be a promising approach for CTI ablation. Larger prospective and randomized trials are needed to establish its long-term efficacy and clinical utility. Graphical Abstract
Mehta et al. (2026) conducted a meta-analysis in Cavotricuspid isthmus-dependent atrial flutter. Pulsed field ablation (PFA) was evaluated on Acute bidirectional CTI block (95% CI 96.8-99.5). Pulsed field ablation for CTI-dependent atrial flutter demonstrated high procedural effectiveness, achieving a pooled acute bidirectional block rate of 98.1% (95% CI: 96.8-99.5).