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. This paper highlights tips and techniques for using the 9-electrode circular array PulseSelect™ Pulsed Field Ablation catheter, including setup and workflow for pulmonary vein isolation and other atrial ablation targets, as well as common pitfalls to avoid, in order to maximize safety, efficiency and efficacy. PulseSelect is a versatile pulsed field ablation catheter that is being increasingly adopted by electrophysiologists. Its forward-tilt and circular/’horseshoe’-shaped design lends to tactile and visual contact feedback fluoroscopically. It can also be used with electro-anatomic mapping for ablation to pulmonary veins and beyond. We describe our tips and techniques to optimise ablation of various potential arrhythmia targets.