Feasibility, Safety and Procedural Characteristics of Focal Pulsed Field Ablation for Ventricular Arrhythmias

Background
Pulsed field ablation (PFA) is a non-thermal ablation technique based on irreversible electroporation, allowing selective myocardial ablation while sparing surrounding structures such as the esophagus and phrenic nerve. While its role in atrial fibrillation treatment is well described, data on ventricular applications are limited. We report our single-center experience using focal PFA, alone or in combination with radiofrequency (RF), for the treatment of premature ventricular complexes (PVCs) and ventricular tachycardia (VT) with the CENTAURI™ system (CardioFocus, Marlborough, MA, USA).

Methods
Sixteen patients (mean age 62.5 ± 19.1 years; 12 male) underwent catheter ablation for symptomatic, drug-refractory ventricular tachycardia (n=9) or frequent premature ventricular complexes (n=7) between January 2023 and May 2025 at our center. A subset presented with electrical storm (n=3) or had a history of resuscitated cardiac arrest (n=1). In total, 6 patients (38%) underwent at least one prior ventricular ablation before the index procedure, while 10 patients (62%) were treated with PFA as their first ablation. Ablation targets included the left ventricular (LV) summit, mitral annulus (lateral, anterior, and inferoseptal segments), papillary muscles, and the right ventricle (RV), specifically the right ventricular outflow tract (RVOT) and lateral wall. In two cases, both ventricles were treated. One patient underwent combined epicardial and endocardial ablation. Electroanatomical mapping was performed using the CARTO™ (Biosense Webster, Diamond Bar, CA, USA) system (n=9) or Ensite X™ (Abbott Laboratories, Chicago, IL, USA) (n=7). In 8 patients (50%), PFA was used exclusively. In the other 8, a hybrid RF/PFA strategy was applied when RF alone failed to achieve sufficient lesion effect. Procedural endpoints were elimination of the clinical PVC focus or complete non-inducibility of VT during programmed ventricular stimulation.

Results
Acute procedural success was achieved in 15 out of 16 patients (93.75%). Mean procedure time was 147 ± 48 minutes. Mean fluoroscopy time was 13 minutes, and mean dose area product was 832 cGy*cm². Two major and one minor complications occurred: one third-degree atrioventricular block requiring permanent pacemaker implantation, and one case of femoral vascular bleeding needing surgical intervention. Additionally, one patient developed a femoral pseudoaneurysm, managed conservatively. During follow-up (mean 480 ± 240 days), 9 patients (56%) experienced recurrence of ventricular arrhythmia. All patients who had presented with electrical storm experienced recurrence of VT. Recurrences were more common in patients with reduced left ventricular ejection fraction (<40%) and in those who had undergone prior ablation procedures. Two patients required emergency re-ablation during follow-up. One patient died due to recurrent electrical storm 2 weeks after the initial procedure.

Conclusions
Focal PFA appears feasible and safe for the treatment of ventricular arrhythmias. Procedural success was high, and complication rates remained within an acceptable range in this high-risk cohort. Long-term control remains difficult in complex substrates, especially in redo procedures, underlining the need for further optimization. In selected cases, the combination of PFA with focal RF may help overcome anatomical or lesion-depth limitations.