Fluoroless Mapping and Ablation With Integration of a Pentaspline Pulsed Field Catheter.

Introduction: Fluoroless mapping and ablation using a Pentaspline pulsed field ablation catheter has many advantages. This can be achieved using a "tripolar configuration," which enables high-quality electroanatomical maps, improves the ability to localize electrograms (EGMs), and minimizes the use of additional mapping catheters compared to the standard bipolar configuration. We aimed to evaluate the benefits of using a tripolar configuration in fluoroless atrial fibrillation ablation compared to the standard bipolar configuration.

Methods: In the tripolar pinning configuration, visualization includes not only the 3rd electrode but also the interpolation of electrodes 1, 2, & 4 on each spline. Procedures were performed under general anesthesia, and the EnsiteX system (Abbott, Abbott Park, IL) was used for mapping. Intracardiac echocardiography and electro-anatomical mapping were used to identify catheter location and record local EGMs. Tripolar and standard bipolar signals were displayed on the same page to evaluate the signals before and after each PFA application. We compared the peak-to-peak signal voltage between the tripolar and standard configurations.

Results: Ablation was performed in 59 cases (42 males, average age 65 (30-85); 17 females, average age 74 (59-83)) in which we configured the catheter in a tripolar setup for comparison with the standard bipolar setup. Geometry and post-voltage maps were created using the tripolar signals in 40 of the 59 patients. The average case duration was 85 min (53-198); for pulmonary vein isolation (PVI) alone, the average was 70 min (53-97). The average number of PFA applications was 48 (31-72). Standard bipolar EGMs demonstrated a large far-field component, as evidenced by significantly higher mean (84%) and root mean square (RMS, 51%) values compared to the tripolar configuration (p < 0.001). Ectopic atrial foci and atrial flutters were successfully mapped and ablated in four and five patients, respectively. We were able to demonstrate lines of block across the mitral isthmus and the cavotricuspid isthmus ablation. In cases where mapping was performed, geometry creation with the tripoles allowed for field scaling on Ensite X.

Conclusion: Integration of the Pentaspline pulsed field ablation catheter with the tripolar configuration is feasible and facilitates fluoroless PVI.