Pulsed field ablation of the cavotricuspid isthmus using a balloon-in-basket system

Pulsed field ablation (PFA) has emerged as a promising modality for pulmonary vein isolation (PVI) in atrial fibrillation (AF), with favourable safety and efficacy profiles. However, its application to other arrhythmias, such as typical atrial flutter (AFl), remains exploratory. The Volt™ PFA system (Abbott Laboratories), a novel balloon-in-basket catheter capable of mapping, pacing and delivering ablating energy, has been validated for PVI, but has not yet been used for the treatment of AFl cavotricuspid isthmus (CTI) dependent. We report the first documented case of successful concomitant PVI and CTI ablation using the Volt™ PFA system. A 73-year-old male with persistent AF and atrial flutter was referred for catheter ablation. After PVI was completed, typical AFl was induced during catheter manipulation. Activation mapping and entrainment confirmed CTI-dependent flutter. Despite the presence of a pacemaker and the balloon-shaped catheter, a linear ablation line was delivered across the CTI using selectively activated splines. Tachycardia was terminated after six PFA applications, and bidirectional CTI block was confirmed. The patient was discharged two days post-procedure without complications.

This case demonstrates the feasibility of using the balloon-in-basket Volt™ PFA catheter for CTI ablation. Mapping integration and selective spline activation enabled precise lesion placement in a linear anatomical region, overcoming the expected limitations of a balloon-based system. While the acute outcome was successful, long-term safety and efficacy of this off-label use warrant further investigation.