VENTRICULAR tachycardia ablation data suggests that bipolar radiofrequency ablation (Bi-RFA) remains the preferred advanced strategy for difficult intramural ventricular tachycardia (VT).
According to the review, Bi-RFA has become an established second line treatment for intramural VT that is refractory to conventional unipolar approaches.
By delivering energy between two catheters positioned on opposing myocardial surfaces, the technique can create transmural lesions across interventricular septal wall thicknesses of up to 15 mm.
Clinical evidence supporting Bi-RFA is currently stronger than that available for pulsed field ablation.
Acute success rates of 75 to 89% have been reported across multicentre registries.
The largest registry analysed included 94 procedures performed across 16 European centres and demonstrated that the technique is feasible with an acceptable safety profile.
The researchers noted that although long-term arrhythmia freedom remains modest and randomised comparative trials are lacking, Bi-RFA has established a clear role in the management of refractory intramural VT.
Pulsed field ablation is an emerging non-thermal technology that uses electroporation rather than heat to achieve tissue destruction.
Preclinical studies in swine models demonstrated deeper and more transmural lesions than radiofrequency ablation in scarred myocardium.
This advantage may result from its ability to penetrate fibrotic and fatty tissue that can limit thermal energy delivery.
The first in human VCAS trial evaluated pulsed field ablation in 26 patients and reported an acute procedural success rate of 92%.
Investigators also observed a 98% reduction in VT or ventricular fibrillation (VF) burden following treatment.
However, freedom from recurrent VT or VF at follow up remained more limited.
A recent meta-analysis reported a mid-term freedom from recurrence of 63%, highlighting potential concerns regarding lesion durability.
The review concluded that Bi-RFA currently remains the preferred advanced option for VT refractory to unipolar radiofrequency ablation because it is supported by the largest body of clinical evidence.
The researchers emphasised that further prospective randomised trials are needed before pulsed field ablation can be considered a standard alternative.
Reference
Potel KN et al. Novel Approaches to Ablation for Ventricular Tachycardia – What Is the Role for Bipolar Radiofrequency Ablation versus Pulsed Field Ablation Targeting Difficult Ventricular Tachycardia Substrates?. Curr Cardiovasc Risk Rep. 2026;DOI:10.1007/s12170-026-00784-1
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