# Managing Catheter Knotting in Pulse‐Select Pulsed Field Ablation: Mechanisms and a Practical Strategy for Resolution

## TL;DR

This paper describes two types of PulseSelect catheter knotting and a non-forceful strategy to resolve them safely during atrial fibrillation ablation.

## Contribution

The study introduces a practical, non-forceful resolution strategy for PulseSelect catheter knotting based on its elasticity.

## Key findings

- Two reproducible types of PulseSelect catheter knotting were identified.
- A structured resolution strategy resolved 96% of Type 1 and 100% of Type 2 knots without damaging the catheter.
- The technique enhanced procedural safety and preserved catheter usability.

## Abstract

Pulsed field ablation (PFA) using the PulseSelect catheter is effective for atrial fibrillation but may occasionally result in catheter deformation or knotting.

We analyzed 25 PulseSelect catheters used for AF ablation to identify knotting mechanisms. Two reproducible knot types were observed. A resolution strategy was tested: retraction to the sheath tip, wire withdrawal, and gradual advancement with or without rotation.

The knot was resolved in 24 catheters (96%), with 21 (84%) resolved on the first attempt. One severe type 1 knot was resistant but safely removed.

A structured, non‐forceful approach utilizing the catheter's elasticity effectively resolves knotting without rendering the catheter unusable.

This study describes two types of PulseSelect catheter knotting and demonstrates a simple, non‐forceful resolution strategy. This technique, which utilizes the catheter's inherent elasticity, successfully resolved Type 1 knotting in 96% and Type 2 knotting in 100%, enhancing procedural safety without damaging the device.