Efficacy and safety of pulsed field ablation for cavotricuspid isthmus-dependent atrial flutter: A meta-analysis based on real-world evidence.

BACKGROUND: Pulsed field ablation (PFA) is effective for atrial fibrillation, but its real-world performance for cavotricuspid isthmus (CTI)-dependent atrial flutter remains inadequately defined. OBJECTIVE: The purpose of this study was to systematically evaluate the efficacy and safety of PFA for CTI ablation using real-world evidence. METHODS: A total of 9 observational studies (656 patients) published up to January 2026 were analyzed using a random-effects model. RESULTS: Pooled analysis revealed a short-term bidirectional CTI block rate of 99.4% and a short-to-midterm recurrence rate of 2.14%. Mean CTI ablation time was highly efficient (8.86 minutes). Incidences of catastrophic complications and permanent atrioventricular block were 0%. The overall incidence of intraprocedural right coronary artery spasm was 2.0%. Prophylactic high-dose intravenous nitroglycerin (>1 mg) significantly reduced coronary spasm incidence compared with low-dose (≤1 mg) regimens (1% vs 8%; P = .0016). Sensitivity analyses confirmed spasm risk was independent of PFA catheter configuration (P = .9549). CONCLUSION: PFA is a rapid, safe, and highly effective modality for CTI ablation. The risk of transient coronary spasm may be mitigated with prophylactic high-dose nitroglycerin. These hypothesis-generating findings warrant further validation.