Pulsed Field Ablation With the Volt System for Recurrent Atypical Atrial Flutter in a Patient With Extensive Prior Ablation: A Case Report

Background Recurrence of atrial flutter after extensive left- and right-atrial ablation strategies poses a significant clinical challenge, particularly in patients with complex atrial substrates. The use of pulsed field ablation (PFA) with a balloon-in-basket system (Volt™, Abbott) represents a novel platform with promising myocardial tissue selectivity. However, clinical experience targeting extra-pulmonary vein substrate remains limited, with few reported cases to date. Case summary We describe a 59-year-old woman with recurrent symptomatic atypical atrial flutter despite multiple prior radiofrequency ablation procedures, which included cavotricuspid isthmus (CTI) ablation, pulmonary vein isolation (PVI), a left atrial roofline, posterior mitral isthmus ablation, and additional ablation at the base of the left atrial appendage, for persistent atrial fibrillation and atrial flutter. The patient developed left ventricular systolic dysfunction, which was attributed to arrhythmia and improved after restoration of sinus rhythm. Due to intolerance of sotalol, propafenone and amiodarone, and symptomatic flutter recurrence, she was listed for redo ablation using PFA (Volt). After confirming the presence of an atypical atrial flutter within the left atrium, PFA using the balloon-in-basket catheter was employed to target the substrate for atypical flutter. Atrial flutter terminated with delivery of pulsed field ablation without acute complications. The patient remained in stable sinus rhythm without recurrence of atrial tachyarrhythmia during three-month follow-up. Discussion This case highlights the feasibility and potential efficacy of PFA using the balloon-in-basket catheter in treating complex atrial flutter after multiple failed conventional ablations.