Key result
PFA successfully ablates Marshall Bundle-related perimitral atrial flutter following failed RF ablation.
Why the study?
Perimitral atrial flutter is challenging due to complex mitral isthmus anatomy and epicardial conduction via the Marshall bundle, which hinders complete lesion and bidirectional block.
Case Report
Pulsed-field ablation may be a potential strategy for achieving mitral isthmus block in Marshall Bundle-related perimitral atrial flutter.
PFA may overcome Marshall bundle conduction in perimitral AFL; hypothesis-generating and requires prospective validation.
Perimitral atrial flutter (AFL) is one of the most challenging arrhythmias due to the complex anatomical characteristics of mitral isthmus and associated epicardial structures.1 Epicardial conduction through the Marshall bundle across the mitral isthmus remains a major barrier in achieving complete lesion and bidirectional block. Successful interruption of the perimitral circuit requires precise understanding of the anatomical relationship at the Marshall bundle insertion site. Pulsed-field ablation (PFA) has been established as a rapid, safe, and effective modality for pulmonary vein (PV) isolation with durable outcomes,2 and has emerged as a potential strategy following failed radiofrequency (RF) ablation for mitral isthmus block.
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Park et al. (2026) conducted a case report in Perimitral atrial flutter (AFL). Pulsed field ablation (PFA) was evaluated. Pulsed field ablation was successfully used to ablate Marshall Bundle-related perimitral atrial flutter, offering a potential strategy following failed radiofrequency ablation.
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