Ventricular-Pulsed Field Ablation for Ventricular Arrhythmias: Pooled Effectiveness, Safety, and Mid–term Recurrence From 43 Clinical Studies

Background Ventricular pulsed field ablation (PFA) is increasingly adopted for ventricular arrhythmias, yet the evidence base remains fragmented. Purpose To pool outcomes of ventricular PFA across indications (PVC, VT), estimate between–study heterogeneity, and test robustness in analyses restricted to cohorts with ≥3 patients. Methods We performed a systematic review and meta–analysis of clinical reports to 10 October 2025. Primary endpoints were: (1) acute success (PVC: elimination of the clinical focus; VT: non–inducibility), (2) intra/≤30–day complications, and (3) recurrence incidence (events per patient–year) at longest follow–up. Proportions were synthesised with generalised linear mixed models. Recurrence was modelled using mixed–effects Poisson models with a person–time offset. Overlapping reports were de–duplicated at patient level; a prespecified sensitivity included only cohorts with ≥3 patients (Figure 1). Results 355 patients (PVC 122, VT 233) from 43 studies were included; mean age 59.3±14.8 years. Mean LVEF was 53.9±11.7% in PVC and 34.8±12.6% in VT. Redo procedures in 43% of all index PFA sessions. Main etiology was ischemic cardiomyopathy in VT group (51%) and idiopathic in PVC group (72%). Mean follow–up was ∼5 months (PVC 155±79 days; VT 152±44 days). Six distinct PFA ablation systems were identified across studies. Hybrid workflows (PFA+RF) occurred in 38%. On average, JBI risk of bias ratings were moderate. (1) Acute effectiveness: In ≥3–patient cohorts, pooled success was 93% (95% CI 85–99; I²=0%) for PVC and 89% (95% CI 83–93; I²=0%) for VT. When all studies were pooled, estimates were ≈100% (PVC) and ≈99% (VT), with I²=0% for both, consistent with small–study/publication effects (Figure 2). (2) Safety (≤30 days): In ≥3–patient cohorts, complications were 8% (95% CI 1–21; I²≈47%) for PVC and 10% (95% CI 5–15; I²=0%) for VT. Across all studies, model–based pooled proportions were ≈1% with I²=0% in both indications (Figure 2) (3) Recurrence: Incidence was 0.33 events/patient–year for PVC (I²=0%) and 0.40–0.44 for VT, with modest heterogeneity for VT (I²≈28% in ≥3–patient analyses); the VT prediction interval was ≈0.19–1.25 events/patient–year, reflecting variability in substrate, approach, and surveillance (Figure 2). Conclusion Across heterogeneous platforms and workflows, ventricular PFA demonstrates high acute effectiveness and near–term safety, and acceptable mid–term durability. Estimates restricted to ≥3 patients studies appear more generalisable than all–study pools.