Novel Approaches to Ablation for Ventricular Tachycardia – What Is the Role for Bipolar Radiofrequency Ablation versus Pulsed Field Ablation Targeting Difficult Ventricular Tachycardia Substrates?

Purpose of Review Ventricular tachycardia (VT) arising from deep intramural and mid-septal substrates remains one of the most difficult challenges in VT management. Conventional unipolar radiofrequency ablation (RFA) is limited to lesion depths of 5–6 mm, frequently insufficient to reach these targets. This review evaluates the current evidence, practical implementation, and comparative merits of two advanced energy modalities — bipolar radiofrequency ablation (BRFA) and pulsed field ablation (PFA) — for the treatment of difficult VT substrates. Recent Findings BRFA has emerged as an established second-line strategy for intramural VT refractory to unipolar approaches, achieving transmural lesions across interventricular septal wall thicknesses up to 15 mm, with acute success rates of 75–89% across multicenter registries. The largest registry to date (94 procedures, 16 European centers) confirmed its feasibility and acceptable safety profile. PFA represents a promising emerging modality; preclinical swine models demonstrate deeper and more transmural lesions than RFA in scarred myocardium due to its nonthermal electroporation mechanism. The first-in-human VCAS trial ( n = 26) reported 92% acute procedural success with a 98% reduction in VT/VF burden. However, mid-term VT freedom remains modest at 63%, and no randomized comparison with RFA exists. Summary BRFA is currently the preferred advanced ablation strategy for intramural VT refractory to unipolar RFA, supported by the largest body of clinical evidence. PFA shows compelling preclinical depth advantages and early clinical promise but requires prospective randomized trials before it can be considered a standard alternative. Optimal integration of imaging-guided substrate characterization with individualized energy delivery strategies represents the future of precision VT ablation.