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Background  The aim of this study was to explore whether the pouch depth influenced the radiofrequency ( RF ) duration and total delivered  RF  energy for cavotricuspid isthmus ( CTI ) ablation and define the cutoff value for a deep pouch‐specified ablation strategy.    Methods  This study included 94 atrial fibrillation ( AF ) patients (56 males, age 68 ± 8.0 years). With intracardiac echocardiography, the isthmus length and pouch depth were precisely measured. After a standard  AF  ablation, all patients underwent the  CTI  ablation along the lateral isthmus. If bidirectional block could not be achieved, the ablation catheter was deflected more than 90 degrees to ablate inside the pouch (knuckle‐curve ablation).    Results  Seventy‐two patients (76.6%) had a sub‐Eustachian pouch. Bidirectional block could be achieved in all patients. By a univariate logistic regression analysis, only the pouch depth was significantly correlated with the  RF  duration ( P  = .005) and  RF  energy ( P  = .006). A multivariate logistic regression analysis also revealed the pouch depth was the sole factor that influenced the  RF  duration ( P  = .001) and  RF  energy ( P  = .001). Among the 72 patients, 21 patients needed a knuckle‐curve ablation. Using a receiver operating characteristic curve, the optimal cutoff value of the pouch depth for a knuckle‐curve ablation was 3.7 mm with a sensitivity of 90% and specificity of 69%.    Conclusions  The sub‐Eustachian pouch depth was the sole factor that influenced the  RF  duration and energy in the  CTI  ablation. If the pouch was deeper than 3.7 mm, a deep pouch‐specified ablation strategy would be needed.

journal of arrhythmia

The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed—Cavotricuspid isthmus ablation using intracardiac echocardiography