Background: Although tissue contact significantly affects pulsed field ablation (PFA) efficacy, evidence supporting contact force-guided PFA for recurrent left atrial flutter (AFL) remains scarce. In this study we investigated the efficacy and safety of PFA in this difficult-to-treat population compared with radiofrequency ablation (RFA).
Methods: Patients with atypical AFL who had undergone at least 1 previous persistent atrial fibrillation ablation were prospectively enrolled for PFA and compared with a retrospectively analyzed control group treated with conventional RFA at the same period. Coronary artery spasm risk was assessed via coronary angiography. The efficacy end points were recurrence of atrial arrhythmias after a 3-month blanking period. The safety end point included severe procedure-related complications.
Results: A total of 253 patients were included in this study (mean age 59 years, 68% male), 119 patients received PFA treatment, 134 patients received RFA. At 12-month follow-up, the RFA group demonstrated a significant higher atrial tachyarrhythmia recurrence rate compared with the PFA group (36% vs 24%; log rank P = 0.027). In the multivariable Cox regression model, PFA was linked to lower risk of the recurrence risk compared with RFA (hazard ratio, 0.56; 95% confidential interval, 0.35-0.90; P = 0.017). Moreover, acute mitral isthmus block rate in the PFA group was significantly higher than in the RFA group (100% vs 64%; P < 0.001). No procedure-related complications were observed, including esophageal fistula, phrenic nerve injury, and coronary artery spasm.
Conclusions: In patients with refractory left AFL post atrial fibrillation ablation, contact force-guided PFA appears promising and demonstrates favourable efficacy compared with conventional RFA.
Keywords: Pulsed field ablation; atrial fibrillation; atrial flutter; coronary artery spasm; mitral isthmus.
Copyright © 2026. Published by Elsevier Inc.