Key result
Distal-to-proximal conduction system ablation achieves acute PVC elimination in ~96% of patients.
Why the study?
Ablation of premature ventricular contractions originating from the Purkinje network with multiple exit sites and morphologies poses a significant clinical challenge when conventional ablation fails. The safety and efficacy of proximal conduction system ablation as an alternative strategy in these refractory cases needed evaluation.
Does distal-to-proximal conduction system ablation safely and effectively eliminate arrhythmias in patients with drug-refractory, symptomatic multi-exit Purkinje premature ventricular contractions and ventricular fibrillation?
Cohort (n=22)
Does distal-to-proximal conduction system ablation safely and effectively eliminate arrhythmias in patients with drug-refractory, symptomatic multi-exit Purkinje premature ventricular contractions and ventricular fibrillation?
Distal-to-proximal conduction system ablation achieves high acute success (95.5%) and prevents recurrent ventricular fibrillation in patients with refractory multi-exit Purkinje PVCs, though with a 22.7% rate of conduction disturbances.
May support bailout ablation in refractory Purkinje cases; leaves open need for prospective validation before wider adoption.
BACKGROUND: Ablation of premature ventricular contractions (PVCs) originating from the Purkinje network-particularly those with multiple exit sites and morphologies-poses a significant clinical challenge. In refractory cases where conventional ablation fails, proximal conduction system ablation may represent a viable alternative strategy. OBJECTIVE: to evaluate the safety and efficacy of proximal conduction system ablation in patients with refractory multi-exit Purkinje PVCs with diverse morphologies. METHODS: This retrospective cohort included consecutive patients with drug-refractory, symptomatic Purkinje PVCs who underwent proximal conduction system ablation. Multiple exit sites and morphologies were observed during mapping and ablation, indicating complex activation within the Purkinje network. RESULTS: Among the 22 patients included, 14 (63.6%) had PVC-triggered ventricular fibrillation. Acute elimination of the PVC by distal-to-proximal conduction system ablation achieved in 21 patients (95.5%), while one procedure (4.5%) was discontinued at the patient's request due to the anticipated risk of conduction system injury. The initial site of earliest activation arose from the posterior fascicle in 63.6% (n=14), the septal fascicle in 22.7% (n=5) and the anterior fascicle in 13.6% (n=3). During ablation, all patients demonstrated a shift in the site of earliest activation. Conduction disturbances occurred in 5 patients (22.7%). During a median follow-up of 32.3 months (IQR 17.5-54.5), one patient (4.5%) experienced PVC recurrence requiring repeat ablation; however, no patient experienced recurrent ventricular fibrillation. CONCLUSION: Distal-to-proximal conduction system ablation can be an effective bailout strategy for patients with refractory multi-exit fascicular/Purkinje-related PVCs and recurrent VF. Larger prospective studies are needed to confirm its long-term safety and efficacy.
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Khalaph et al. (2026) conducted a cohort in Refractory multi-exit Purkinje-related premature ventricular contractions and ventricular fibrillation (n=22). Distal-to-proximal conduction system ablation was evaluated on Acute elimination of premature ventricular contractions. Distal-to-proximal conduction system ablation achieved acute PVC elimination in 95.5% of patients, with 4.5% PVC recurrence and no recurrent VF over 32.3 months.
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