A substudy of the ADVANTAGE AF trial has demonstrated that for treating typical atrial flutter (AFL), pulsed field ablation (PFA) is as effective and safe as conventional radiofrequency ablation (RFA), but significantly more efficient.¹ The study focused on adjunctive cavotricuspid isthmus (CTI) ablation, a common procedure performed during atrial fibrillation (AF) ablation.
Mechanism of Action
PFA is a non-thermal ablation modality that uses high-voltage electrical pulses to create lesions via irreversible electroporation. This process is thought to offer greater tissue selectivity, potentially sparing non-myocardial structures like nerves and blood vessels compared to thermal ablation methods.
Methodology
This substudy of the prospective, single-arm ADVANTAGE AF trial (NCT05443594) involved a non-randomised comparison between two cohorts of patients with persistent AF undergoing adjunctive CTI ablation.¹ The first phase included 50 patients treated with irrigated RFA. The second phase included 141 patients treated with a bipolar linear PFA catheter (Farapoint). To mitigate the risk of coronary artery spasm, patients in the PFA group were pretreated with a vasopressor bolus followed by high-dose intravenous nitroglycerin. The primary efficacy endpoint was acute CTI conduction block, with procedural time and safety events also assessed.
Results
The study found that acute CTI conduction block was achieved in 100% (50 of 50) of patients in the RFA group and 98.6% (139 of 141) in the PFA group, demonstrating comparable high efficacy (P=1.00).¹
A key difference emerged in procedural efficiency. CTI ablation time was significantly shorter with PFA, with a median time of 5 minutes (interquartile range [IQR]: 4–8 min) compared to 14 minutes for RFA (IQR: 9–19 min; P=0.001).
Safety outcomes were similar, with safety event rates of 2.0% in the RFA group and 2.1% in the PFA group (P=0.96). Notably, the use of the nitroglycerin pretreatment protocol in the PFA cohort resulted in no clinical manifestations of coronary artery spasm.
In Practice
These findings suggest that for CTI-dependent AFL, a linear PFA catheter provides safety and efficacy on par with standard RFA, while offering a significant improvement in procedural speed. The substudy also establishes a standardised coronary safety protocol that appears effective in preventing coronary spasm, a potential concern when using PFA near the coronary arteries. While not a randomised comparison, the data supports PFA as an efficient alternative for CTI ablation.²
References
1. Gerstenfeld EP, Schmidt B, Natale A, et al. Pulsed Field Ablation vs Standard Radiofrequency Ablation for Typical Atrial Flutter: ADVANTAGE AF Trial Substudy. J Am Coll Cardiol. 2026;87(14):1764-1778. https://doi.org/10.1016/j.jacc.2025.12.081
2. Reddy VY, Gerstenfeld EP, Natale A, et al. Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med. 2023;389:1660-1671. https://doi.org/10.1056/NEJMoa2307291
This study was funded by Boston Scientific.
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