Introduction: Fluoroless mapping and ablation using Pentaspline pulsed field ablation catheter has many advantages. This can be achieved using “tripolar configuration” which enables high-quality electroanatomical maps, improved ability to localize EGMs, minimize use of additional mapping catheter when compared to the standard bipole configuration. We aimed to evaluate the benefits of using tripolar configuration in fluoroless atrial fibrillation ablation when compared to the standard bipolar configuration. Methods: The study was approved by the local Institutional Review Board. This study aims to compare a standard method of pinning the pentaspline catheter to an alternative “tripolar pinning” technique. In the tripolar pinning configuration, visualization of not only the 3rd electrode but also the “interpolation of electrode 1, 2, & 4 on each spline is done. Procedures were performed under general anesthesia, EnsiteX system (Abbott, Abbott Park, IL) was used for mapping. Intracardiac echo and electroanatomical map was used to identify catheter location and identify local EGMs. Tripole and standard bipole signals were displayed on the same page to evaluate the signals pre and post each PFA application. 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 tripole for comparison with the standard bipole setup. Geometry and post voltage maps were created using the tripolar signals in 40 of the 59 patients. Average case duration was 85 minutes (53 – 198; PVI alone 70 minutes (53 – 97)). The average number of PFA applications was 48 (31 – 72). Standard bipole EGMs demonstrated a large far field component when compared to tripole configuration. Ectopic atrial foci, atrial flutters were successfully mapped and ablated in four and five patients respectively. We were able to demonstrate line of block across mitral isthmus and 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.

Radiofrequency (RF) ablation for the treatment of atrial fibrillation has gained widespread acceptance since the concept was introduced by Haissaguerre et al a quarter of a century ago. High power short duration ablation has been widely adopted in the management of atrial fibrillation. Evidence for combining lesion size index and high power short duration ablation is lacking. In this issue of the journal, Cai et al evaluated the combination of HPSD with LSI with a focus on long-term efficacy.

Background: Surgical or percutaneous occlusion of the left atrial appendage (LAA) is increasingly used for thromboembolic protection in atrial fibrillation. Incomplete LAA closure may increase risk of thrombosis and thromboembolism, and therefore approaches to address residual communications are needed. Objective: To analyze the technique of closing an incompletely occluded LAA and subsequent patient outcomes. Methods: We performed a retrospective analysis of 5 consecutive patients who presented for completion of LAA closure. Results: Four patients were male, mean age 75, average CHA2DS2-VASc score 5.4, and four had prior surgical LAA ligation. One patient had previously had a WATCHMAN device placed for whom a 3D printed model was created from preprocedural imaging data to guide Amplatzer occluder device selection for closure. The residual LAA communication maximal diameter averaged 6.2 mm (range 5-8mm). In 4 of 5 cases, an ablation catheter was used to enter the LAA. The residual LAA communication was closed with either an Amplatzer occluder (n=3) or a WATCHMAN device (n=2). No procedural complications occurred, and no residual leak remained afterwards. No neurologic events occurred during follow up (average 603 days, range 155-1177 days). Anticoagulation or dual antiplatelet therapy was stopped following a transesophageal echo (TEE) ³ 6 weeks after the procedure demonstrated no residual communication in 4 of 5 patients, and after 20 weeks in the fifth patient without a follow up TEE. Conclusion: Large residual LAA communications after LAA occlusion attempts can be successfully and safely closed percutaneously using either Amplatzer occluder devices or WATCHMAN devices.