Pulsed Field Ablation vs Standard Radiofrequency Ablation for Typical Atrial Flutter: ADVANTAGE AF Trial Substudy

Edward P Gerstenfeld¹, Boris Schmidt², Andrea Natale³, Devi Nair⁴, Walid Saliba⁵, Atul Verma⁶, Philipp Sommer⁷, Andreas Metzner⁸, Thomas A Dewland⁹, Joshua D Moss⁹, Anish Amin¹⁰, Jean Champagne¹¹, Frank Cuoco¹², Troy Hounshell¹³, Ziad Issa¹⁴, Mohit Turagam¹⁵, Richard Brose¹⁶, Torri Schwartz¹⁶, Jonathan D Raybuck¹⁶, Ania Garlitski¹⁶, Moussa Mansour¹⁷, Vivek Y Reddy¹⁵

Affiliations

¹ University of California-San Francisco, San Francisco, California, USA. Electronic address: edward.gerstenfeld@ucsf.edu.
² Cardioangiologisches Centrum Bethanien, Frankfurt, Germany.
³ Texas Cardiac Arrhythmia Research, Austin, Texas, USA.
⁴ St Bernards Medical Center &-Arrhythmia Research Group, Jonesboro, Arkansas, USA.
⁵ Cleveland Clinic Foundation, Cleveland, Ohio, USA.
⁶ McGill University Health Centre, Montréal, Québec, Canada.
⁷ Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany.
⁸ University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany.
⁹ University of California-San Francisco, San Francisco, California, USA.
¹⁰ Ohio Health, Cleveland, Ohio, USA.
¹¹ Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada.
¹² Trident Medical Center, Charleston, South Carolina, USA.
¹³ MercyOne Iowa Heart Center, West Des Moines, Iowa, USA.
¹⁴ St John's Hospital, Springfield, Illinois, USA.
¹⁵ Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA.
¹⁶ Boston Scientific, St Paul, Minnesota, USA.
¹⁷ Massachusetts General Hospital, Boston, Massachusetts, USA.

PMID: 41653174
DOI: 10.1016/j.jacc.2025.12.081

Pulsed Field Ablation vs Standard Radiofrequency Ablation for Typical Atrial Flutter: ADVANTAGE AF Trial Substudy

Edward P Gerstenfeld et al. J Am Coll Cardiol. 2026.

. 2026 Feb 6:S0735-1097(26)00055-0.

doi: 10.1016/j.jacc.2025.12.081. Online ahead of print.

Authors

Affiliations

¹ University of California-San Francisco, San Francisco, California, USA. Electronic address: edward.gerstenfeld@ucsf.edu.
² Cardioangiologisches Centrum Bethanien, Frankfurt, Germany.
³ Texas Cardiac Arrhythmia Research, Austin, Texas, USA.
⁴ St Bernards Medical Center &-Arrhythmia Research Group, Jonesboro, Arkansas, USA.
⁵ Cleveland Clinic Foundation, Cleveland, Ohio, USA.
⁶ McGill University Health Centre, Montréal, Québec, Canada.
⁷ Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany.
⁸ University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany.
⁹ University of California-San Francisco, San Francisco, California, USA.
¹⁰ Ohio Health, Cleveland, Ohio, USA.
¹¹ Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada.
¹² Trident Medical Center, Charleston, South Carolina, USA.
¹³ MercyOne Iowa Heart Center, West Des Moines, Iowa, USA.
¹⁴ St John's Hospital, Springfield, Illinois, USA.
¹⁵ Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA.
¹⁶ Boston Scientific, St Paul, Minnesota, USA.
¹⁷ Massachusetts General Hospital, Boston, Massachusetts, USA.

PMID: 41653174
DOI: 10.1016/j.jacc.2025.12.081

Abstract

Background: ADVANTAGE AF examined the safety and efficacy of pulsed field ablation (PFA) to treat persistent atrial fibrillation (AF). During AF ablation, typical atrial flutter (AFL) is commonly treated with cavotricuspid isthmus (CTI) ablation.

Objectives: Adjunctive CTI ablation in ADVANTAGE AF was performed with radiofrequency ablation (RFA; phase 1) or bipolar linear PFA (phase 2). Here, we compared lesion characteristics, CTI ablation efficacy, and safety between the ablation modalities.

Methods: A preclinical study assessed lesion dimensions with a novel 2.0 kV bipolar linear PFA catheter. In ADVANTAGE AF, after AF ablation with a pentaspline PFA catheter, CTI ablation was performed: in phase 1 with irrigated RFA, and in phase 2 with the linear PFA catheter (Farapoint). Before PFA CTI ablation ,patients were treated with a vasopressor bolus followed by high-dose intravenous nitroglycerin.

Results: Preclinical assessment showed lesion depth increasing at higher field strength and plateauing after 2 applications. In ADVANTAGE AF, 50 and 141 patients received CTI ablation with RFA and PFA, respectively. Patient characteristics across the 2 cohorts were similar (RFA vs PFA). Acute CTI conduction block was similar between techniques (50 of 50 RFA [100%] vs 139 of 141 PFA [98.6%]; P = 1.00). PFA was associated with a shorter CTI ablation time (median: RFA 5 min [Q1-Q3: 4-8 min] vs 14 min [Q1-Q3: 9-19 min]; P = 0.001). RFA and PFA had similar safety event rates (RFA 2.0% vs PFA 2.1%; P = 0.96). With the use of nitroglycerin pretreatment, there was no clinical manifestation of coronary artery spasm with PFA.

Conclusions: This subanalysis of ADVANTAGE AF extends the primary results by allowing comparison of bipolar linear PFA and RF ablation for CTI, integrating preclinical lesion modeling with clinical dosing, and establishing a standardized reliable coronary safety protocol. Although not randomized comparisons, these findings suggest that CTI ablation with a linear PFA catheter is associated with safety and efficacy similar to RF ablation and greater efficiency. (A Prospective Single Arm Open Label Study of the FARAPULSE Pulsed Field Ablation System in Subjects With Persistent Atrial Fibrillation [ADVANTAGE AF; NCT05443594]).

Keywords: ablation; cavotricuspid; coronary artery; flutter; pulsed field.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Gerstenfeld has served as a consultant for and receives lecture honoraria from Boston Scientific; has received lecture honoraria, compensation for data safety monitoring committees, and research support from Abbott, unrelated to the present work; has received lecture honoraria and research support from Adagio Medical, unrelated to the present work; and has served as a consultant to J&J Medtech, unrelated to the present work. Dr Schmidt has served as a consultant for and receives lecture honoraria from Boston Scientific; has received lecture honoraria, compensation for steering committees, and research support from Abbott, unrelated to the present work; has received lecture honoraria and research support from Medtronic, unrelated to the present work; and has served as a consultant to J&J Medtech, unrelated to the present work. Dr Natale has served as a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, Field Medical, iRhythm, Medtronic and Pulse Bioscience. Dr Nair has served as a consultant and advisory board member for and received research grants from Abbott, Boston Scientific, Medtronic, J&J Medtech, Volta, Siemens, and Atraverse. Dr Saliba has consulted for Boston Scientific, Biosense Webster, Volta, Siemens, and Phillips. Dr Verma has received advisory honoraria and grants from JNJ, Abbott, Medtronic, Medlumics, and Adagio Medical. Dr Sommer has served as a consultant for Abbott, Boston Scientific, J&J MedTec, and Medtronic. Dr Metzner has consulted for Medtronic, Boston Scientific, and Biosense Webster. Dr Dewland has received consulted fees from Boston Scientific and Adagio Medical. Dr Amin has consulted for Boston Scientific and Medtronic. Dr Cuoco has consulted for Boston Scientific. Dr Hounshell has consulted for Boston Scientific and Medtronic. Dr Issa has served on the Medical Advisory Board for Boston Scientific. Dr Turagam has consulted for Biosense Webster, Boston Scientific, Medtronic, Abbott, and Sanofi. Mr Brose is an employee of Boston Scientific. Ms Schwartz is an employee of Boston Scientific. Dr Raybuck is an employee of Boston Scientific. Dr Garlitski is an employee of Boston Scientific. Dr Mansour has consulted for Boston Scientific, Biosense Webster, Abbott, Medtronic, Siemens, and SentreHeart/Atricure; and has equity in EPD-Philips (divested) and NewPace. Dr Reddy has received grant support from and serves as an unpaid consultant to Boston Scientific; has served as a consultant for and has equity in Anumana, APN Health, Append Medical, Aquaheart, Atacor, Atraverse, Autonomix, BioSig, CardiaCare, Cardiofocus, CardioNXT/AFTx, Circa Scientific, CoRISMA, Cortex-Boston Scientific, Corvia Medical, Dinova-Hangzhou DiNovA EP Technology, East End Medical, EP Frontiers, Field Medical, Focused Therapeutics, Heartbeam, HRT, Intershunt, Javelin, Kardium, Laminar-JNJ MedTech, LuxMed, Medlumics, Orchestra Biomed, PhysioMap, Pulse Biosciences, Restore Medical, Sirona Medical, SoundCath-Boston Scientific, and Volta Medical, unrelated to the present work; has served as a consultant for Abbott, Adagio Medical, AtriAN, BioTel Heart, Biotronik, BTL, Cairdac, Cardionomic, Conformal Medical, CoreMap, Fire1, Impulse Dynamics, JNJ MedTech, Medtronic, Novartis, Novo Nordisk, Philips, SmartValves, unrelated to the present work; and has equity in DRS Vascular, Manual Surgical Sciences, Newpace, Nyra Medical, Soundcath, Surecor, and Vizaramed, unrelated to the present work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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Pulsed Field Ablation vs Standard Radiofrequency Ablation for Typical Atrial Flutter: ADVANTAGE AF Trial Substudy

Affiliations

Pulsed Field Ablation vs Standard Radiofrequency Ablation for Typical Atrial Flutter: ADVANTAGE AF Trial Substudy

Authors

Affiliations

Abstract

Conflict of interest statement

Associated data

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Medical