Case Report: Pulsed field ablation of an oblique inferoparaseptal accessory pathway

Radiofrequency ablation (RFA) remains the gold standard for Wolff-Parkinson-White (WPW) syndrome with ∼94% acute success, ∼6% recurrence. Pulsed field ablation (PFA) shows promise for complex accessory pathways (APs) but lacks data on oblique courses.

A 36-year-old endurance athlete presented with incidental right paraseptal pre-excitation before methylphenidate initiation. He reported self-terminating palpitations (∼200 bpm) during moderate cycling. Electrophysiological study revealed an oblique inferoparaseptal AP with right atrial insertion (inferior interatrial septum/CS roof, Kent potential) and left inferoparaseptal ventricular exit (earliest retrograde activation mid-CS 5/6). Due to right coronary artery proximity, focal PFA via Centauri™ system (Galvanize) achieved complete CS ostium/roof block. Post-procedure ventricular pacing showed retrograde decremental conduction. At 3 months, he reported no tachycardias/palpitations.

This case demonstrates focal PFA's feasibility for an underrepresented oblique inferoparaseptal AP amid complex CS/CSMC anatomy, avoiding RFA's coronary injury risk. While early PFA series report >99% acute success, randomized long-term data vs. RFA are needed. PFA represents a promising investigational approach for anatomically challenging APs.