Unexpected transient atrioventricular block and slow junctional rhythm using pulsed field ablation for slow pathway modification: Excited or cautious for ablators

Abstract

Background: Data regarding the effects of pulsed field ablation (PFA) on atrioventricular nodal reentrant tachycardia (AVNRT) are limited.

Objective: This study was undertaken to evaluate the outcomes of PFA for AVNRT and its impact on dual-pathway electrophysiology.

Methods: A larger cohort of patients with typical AVNRT underwent slow pathway (SP) modification (SPM) using a focal PFA catheter in a biphasic/bipolar manner. The primary endpoints were the efficacy and safety of PFA during the procedure and at 6-month follow-up.

Results: The acute success of SPM was achieved in all 40 patients. The total ablation time was 7.9 ± 3.8 seconds for 6.4 ± 2.2 ablation sites (ASs). Slow junctional rhythm (SJR) was induced in 32 (80%) patients, lasting 28.9 ± 10.3 seconds in 3.0 ± 1.1 ASs per patient. SP was located 11.1 ± 1.2 mm from the largest His activation (LHA). At 9 ASs, SJR could be reinduced after an increase of contact force (CF) from 1.3 ± 0.5g to 6.4 ± 1.3 g (P < .0001). Transient atrioventricular block (AVB) was recorded in 7 (17.5%) patients (1 second-degree and 6 third-degree AVB) lasting 435.3 ± 227.4 seconds, with a shorter AS-LHA distance than patients without AVB (7.7 ± 0.6 mm vs. 11.3 ± 1 mm; P < .0001). PFA-related delayed atrial-His (n = 6) and His-atrial (n = 1) conduction preceded transient AVB with a constant His-ventricular interval. Normal PR interval was restored within 24 hours. All patients maintained sinus rhythm without any significant adverse events during 6-month follow-up.

Conclusion: Despite the high efficiency of PFA for SPM, the notable incidence of transient AVB warranted caution when applying it near the His bundle. SJR frequently occurred during SPM and was dependent on moderate CF.

Keywords: Atrioventricular block; Atrioventricular nodal reentrant tachycardia; Contact force; Pulsed field ablation; Slow junctional rhythm.