Successful pulsed field ablation for refractory premature ventricular contractions using a novel dual-energy focal...

Radiofrequency ablation (RFA) is an established therapy for symptomatic premature ventricular contractions (PVCs), but arrhythmias from deep intramural substrates may remain refractory. Pulsed field ablation (PFA) is a nonthermal modality with myocardial selectivity, and dual-energy focal catheters allow delivery of both RFA and PFA using a single device. We report successful PFA for RFA-refractory PVCs using this technology.

An 81-year-old man with ischaemic cardiomyopathy and symptomatic monomorphic PVCs was referred after failed prior RFA of both right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT). During repeat ablation, activation mapping identified earliest activation at the septal RVOT and anterior LVOT. Using a dual-energy focal catheter, sequential RFA and PFA were delivered at both sites. In the RVOT, PFA caused only transient suppression with recurrence of PVCs. In the LVOT, the first PFA application failed to eliminate PVCs, whereas additional applications resulted in immediate and sustained suppression. No complications occurred, and the patient remained free of PVCs during follow-up.

This case demonstrates the feasibility of dual-energy focal catheter-based PFA for ventricular arrhythmias refractory to RFA. The elimination of PVCs after repeated PFA suggests that multiple PFA applications may enhance lesion formation in deep intramural substrates. However, this observation should be interpreted cautiously because histological confirmation was unavailable and alternative explanations, including cumulative energy exposure and autonomic variability during conscious sedation, cannot be excluded. Further studies are required to define optimal energy strategy, lesion characteristics, and long-term outcomes of dual-energy ablation for ventricular arrhythmias.