Ablation with the circular pulsed field ablation catheter: Tips & techniques for using the PulseSelect catheter

Pulsed field ablation (PFA) is a novel method of cardiac ablation in which electrical fields create microscopic pores in cardiomyocyte cell membranes, resulting in cell death through a process of electroporation. Unlike thermal technologies, PFA has preferential cardiomyocyte selectivity, thereby reducing the risk of collateral damage to surrounding structures. The PulseSelect PFA system (Medtronic Inc., Minneapolis, MN, USA) is a 9-electrode circular ablation catheter with a central guidewire used for atrial fibrillation ablation. Currently, there is no consensus on workflow or best practice for this catheter. Its distinctive over-the-wire design and forward-tilted flexible electrode array provide considerable procedural versatility and, in our opinion, may offer advantages in terms of selective lesion delivery, reduced haemolysis, and a lower propensity for coronary vasospasm. Realising these potential benefits, however, requires a thorough understanding of catheter geometry, tissue-contact principles, and manipulation techniques. We present our real-world experience from centres in the UK and Spain, highlighting practical concepts, fluoroscopic and electro-anatomic mapping (EAM) strategies, as well as procedural techniques that may help shorten the learning curve, optimise lesion delivery, and safely expand the use of the catheter beyond pulmonary vein isolation.