Feasibility, Safety, and Efficacy of Pulsed Field Ablation for Ventricular Arrhythmias: Insights From a Large Health System Registry in the United States

BACKGROUND: Pulsed field ablation (PFA) is an emerging non-thermal ablation modality with proven safety in atrial arrhythmia ablation. However, data on its performance for ventricular arrhythmias (VA) remain limited. OBJECTIVE: To evaluate the feasibility, safety, and efficacy of PFA for complex VA in a multicenter real-world US registry. METHODS: This retrospective study included consecutive patients undergoing PFA for ventricular tachycardia (VT) or premature ventricular contractions (PVCs) at three Mayo Clinic centers (April 2024 to July 2025). The primary feasibility outcome was the successful delivery of PFA lesions to the intended target substrate. Primary efficacy outcomes included acute procedural success; sustained VT recurrence requiring implantable cardioverter-defibrillator (ICD) shocks or multiple antitachycardia pacing therapies; and ≥ 80% reduction in PVC burden. Safety outcomes included procedural complications, valvular function, thromboembolic events, renal function, and conduction disturbances. RESULTS: Twenty-six patients were included (13 PVC, 13 VT). Acute success was achieved in all VT ablations (69.2% complete; 30.8% partial) and in 92.3% of PVC ablations. Complications occurred in 11.5% of patients (transient LBBB [n = 1] and vascular complications [n = 2]). No thromboembolic events, intracardiac thrombus, or acute kidney injury were observed. Lesions near the mitral valve apparatus did not worsen mitral regurgitation, including in patients with pre-existing valve disease. After a median follow-up of 365 days, one patient experienced VT recurrence requiring ICD shocks. Estimated recurrence-free survival after VT ablation was 61.5% at 12 months; 58.3% of PVC patients achieved ≥ 80% burden reduction. CONCLUSION: PFA for VA appears feasible and acutely effective, with a low rate of procedure-related complications. While acute success was high, long-term outcomes were acceptable for VT ablation and relatively modest for PVC ablation, highlighting the need for continued refinement of technology and energy-delivery strategies. Larger prospective studies are warranted.