Pulsed field ablation (PFA) is an evolving technique in clinical practice for catheter ablation of AF. Because of its non-thermal mechanism (electroporation), it offers significant tissue-sparing advantages. Several preclinical reports have confirmed its safety and efficacy in both atrial and ventricular ablation. Subsequently, a large body of encouraging data has emerged, including randomised clinical trials and real-world registries evaluating several different PFA catheters for left atrial ablation. While preclinical work has detailed the biophysical features and lesion characteristics of PFA, subsequent clinical data have expanded knowledge of the efficacy and safety of various PFA systems. After the success of PFA for atrial arrhythmias, investigations are assessing its utility to treat ventricular arrhythmias. This article briefly reviews biophysical parameters and lesion science and summarises the outcomes of recent clinical studies.
Cardioneuroablation (CNA) has emerged as a therapeutic option for functional bradyarrhythmias and reflex syncope, achieved through parasympathetic denervation via atrial ganglionated plexi ablation. Although efficacy data are encouraging, safety evidence remains limited and heterogeneous. We performed a comprehensive review of complications associated with CNA and integrated these findings with a single-centre experience of 377 consecutive procedures performed in the Institute for Clinical and Experimental Medicine, Prague, Czech Republic, between 2014 and 2026. Reported complications were infrequent and included vascular access complications, pericardial effusion, phrenic nerve injury, coronary artery injury, transient sinus node dysfunction and atrioventricular conduction disturbances. Post-procedural manifestations related to autonomic modulation included inappropriate sinus tachycardia, reduced exercise tolerance and occasional atrial arrhythmias, whereas the impact on ventricular arrhythmogenesis remains uncertain. In our institutional cohort, the overall major complication rate was 1.9% (7/377), including 0.3% (1/377) requiring intervention. No complication resulted in permanent damage or sequelae. CNA appears to have an acceptable safety profile in experienced centres, although complications are probably underrecognised or underreported and long-term prospective data are needed.
Pulsed field ablation (PFA) is a paradigm shift in the field of cardiac electrophysiology. The well-demonstrated success with atrial PFA is generating enthusiasm for ventricular applications of PFA, for which the clinical experience is still in its infancy, however. This study is a systematic review and critical appraisal of the published preclinical and clinical evidence on ventricular PFA, involving a total of 111 primary articles (55 preclinical and 56 clinical). An increasing number of PFA platforms and catheters are being used in the ventricle in clinical practice. This appraisal evaluates the impact of ablation parameters in association with lesion depth and volume, and synthesises the available studies of safety and efficacy outcomes for ablation of ventricular tachycardia and premature ventricular complexes with PFA, as reported in case reports and case series from around the world. The cumulative published evidence amounts to a total of 434 patients ablated with PFA for ventricular arrhythmias, with generally favourable acute and long-term results, while the understanding of safety constraints continues to be explored.
The cardiac conduction system is frequently injured during structural heart disease procedures and it remains difficult to target accurately during conduction system pacing. These current approaches both lead to increased mortality and morbidity. The authors review the anatomical basis, estimated conduction system calibration and subsequent clinical application of a novel CT angiography-based conduction system visualisation platform that enables patient-specific 3D estimation and mapping of the atrioventricular conduction axis for real-time procedural guidance. This breakthrough technology enables clinicians to avoid iatrogenic damage by implanting devices with respect to patient-specific conduction anatomy and to achieve true physiological pacing by targeting precise locations along the conduction system. The authors have applied this visualisation system in more than 2,000 patients undergoing structural heart disease and conduction system pacing procedures, and the results of this early experience are reviewed here. Conduction system-guided intervention provides a framework for a potential shift in cardiac care, with planned prospective trials to further validate these promising outcomes.
