Background: Cavotricuspid isthmus ablation (CTI) is a first line therapy in patients with typical atrial flutter. With the advent of Pulsed Field (PF) as a new energy source, we sought to evaluate the use of PF for CTI ablation. A systematic literature search was conducted on the use of PF for CTI-flutter up to December 2024. A meta-analysis was performed for studies reporting pooled data, while a patient-level summary was done for reports with available individual data. The mean number of PF applications, acute success rate, and prevalence of coronary vasospasm were evaluated. Results: Eleven studies with pooled data from 155 patients were included. All patients had an acute block of the CTI. The mean number of PFA applications was 7.78 (95% CI 6.53–9.48). The incidence of ST-elevation was 0.04% (95% CI 0-2.23%). Subclinical vasospasm was documented in 45% (95% CI 32%–59%) of patients who underwent periprocedural coronary angiography. Prophylactic use of nitrates showed a trend toward reducing the incidence of subclinical vasospasm (RR 0.24, 95% CI 0.06–1.06, p=0.059). Twelve cases with patient-level data were included; six reported complications, including ST elevation and conduction disturbances. Conclusion: PFA for CTI flutter demonstrates high acute success; however, evidence regarding the durability of the block is limited. Clinical vasospasm with ST segment elevation is uncommon but can lead to life-threatening complications. The incidence of subclinical vasospasm is high, and nitrates trend toward reducing this phenomenon. To date, the role of PFA for this condition appears to be limited.
