Procedures were performed with vitamin K antagonist continuation with a target International Normalized Ratio of 2.0–3.0, or uninterrupted direct oral anticoagulant (dabigatran, rivaroxaban, or apixaban given the evening before the procedure if LA arrhythmia considered), under conscious sedation or general anesthesia in a fasting state. All catheters were advanced via the femoral vein after ultrasound-guided venous puncture [3]. A 6F steerable catheter was positioned in the coronary sinus (CS), and served as a reference (Irvine Bio Inc., St. Jude Medical Inc., St. Paul, MN, USA; or 12-pole catheter, Woven®, Boston Scientific). A 3.5 mm open-irrigated contact-force sensing tip (Tacticath Quartz®, Abbott Medical, IL, USA), or impedance-based catheter (Intella Nav Mifi®, Boston Scientific, Natick, MA, USA) was then advanced for CTI ablation. All procedures were performed by three experienced electrophysiologists.

CTI ablation was then performed starting from the ventricular side towards the caval side, targeting a force-time integral (FTI) > 400 gs in a point-by-point manner, as previously described [4]. In case of CTI-dependent flutter, procedure endpoint was arrhythmia interruption with sinus rhythm restoration, and demonstration of a conduction block across the line using electroanatomic activation mapping with UHD system (Rhythmia®, Boston Scientific, Natick, MA, USA) after classical electrophysiological criteria of CTI conduction block have been presented: an activation sequence suggestive of clockwise CTI block at the low lateral right atrium (RA) when pacing at the CS ostium, and the presence of a corridor of separated double potentials all along the ablation line [5]. Power was set at 35 to 45 W, with a flush rate of 17–25 mL/min.

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