Focal pulsed field ablation of cavotricuspid isthmus-dependent atrial flutter: Safety, effectiveness, and mid-term outcomes

Background Cavotricuspid isthmus (CTI) ablation performed using thermal ablation or pentaspline pulsed field ablation (PFA) catheters has demonstrated favorable efficacy and safety. Objective To evaluate the safety, effectiveness, and mid-term outcomes of focal PFA for CTI-dependent atrial flutter. Methods We performed a retrospective analysis of consecutive patients who underwent focal PFA for CTI-dependent AFL between August 2025 and December 2025. The primary endpoints were acute procedural success, periprocedural complications, and recurrence of any documented atrial arrhythmia lasting >30 seconds during follow-up. Results A total of 61 patients underwent CTI ablation with focal PFA. The mean age was 60.4 years, and 36.1% were female. Acute bidirectional conduction block was achieved in all patients (100%), with no cases requiring supplemental radiofrequency ablation to complete the linear lesion. Periprocedural complications included transient ST-segment elevation in 2 patients (3.3%), and PR interval prolongation in 2 patients (3.3%). Over a median 113-day follow-up, 58 (95.1%) of patients remained free from any atrial arrhythmias, with an estimated 180-day event-free survival of 91.9%. Sixty patients (98.4%) did not have typical atrial flutter recurrence, with an estimated 180-day event-free rate of 96.9%. Conclusion Focal pulsed field ablation appears to be a feasible and effective approach for treating CTI-dependent atrial flutter with a satisfactory mid-term outcome. The selection of optimized catheter ablation parameters (bipolar, biphasic, voltage 1800 V, pulse width 10 μs) may help to minimize procedural complication risks. However, larger prospective randomized trials with extended follow-up and systematic monitoring are required to confirm its durable efficacy.