Revisiting ventricular tachycardia ablation: insights into pulsed field energy. A systematic review and meta-analysis of prospective studies

Background

Radiofrequency (RF) ablation remains the cornerstone of ventricular tachycardia (VT) therapy, yet its success is hindered by limited lesion depth in scarred myocardium and the risk of collateral thermal injury. Pulsed field ablation (PFA), inducing irreversible electroporation, may overcome these barriers by achieving deeper and more homogeneous lesions while preserving adjacent structures. Early integration of PFA alone or in hybrid protocols with RF has shown promising results.

Purpose

To evaluate the safety, procedural success, and short-term efficacy of PFA used alone or combined with RF energy for VT ablation.

Methods

A comprehensive search of PubMed, Embase, and Cochrane databases identified six prospective studies enrolling patients undergoing PFA for VT. Case reports were excluded. Pooled analyses were performed in R using a random-effects model with Freeman-Tukey double arcsine transformation. The primary endpoints were (1) acute procedural success, defined as non-inducibility of VT post-ablation, and (2) VT recurrence at 6-month follow-up.

Results

Across six studies, 186 patients were included (mean age 61.7 ± 14.7 years, 89.8% male). Ischemic substrate was present in 63.4%, and 57.5% had a history of previous VT ablation. The mean left ventricular ejection fraction (LVEF) was 33.5 ± 11.4%, with an average follow-up of 167.5 ± 103.4 days.

The pooled rate of acute procedural success was 86.3% (95% CI 80.53 to 91.34, I² = 0%), while 30.3 % (95% CI 19.77 to 41.93, I² = 45.7%) experienced VT recurrence during follow-up (Figure 1). Reported acute complications were rare: coronary artery spasm occurred in 1.98%, stroke in 0.81%, vascular complications in 2.85% and conduction abnormalities in 3.8% (Figure 2).

Conclusion

In early prospective evidence, PFA demonstrates a high acute success rate and favorable short-term outcomes for VT ablation, with minimal procedural complications. Its ability to achieve non-thermal transmural lesions and complement RF energy positions PFA as a promising strategy to improve safety and efficacy in patients with VT.Forest plots of primary outcomesForest plots of secondary outcomes