Aims: Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). Methods and results: This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. Conclusion: Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.

Pulsed field ablation (PFA) has been developed as a largely nonthermal ablation technology with a unique biophysical profile to treat atrial fibrillation. Existing evidence has shown that PFA offers a safe and efficient atrial fibrillation ablation procedure. Among different PFA technologies, the pentaspline FARAPULSE system has been the most extensively used and investigated; however, notable variability exists in workflow, fluoroscopy time, and lesion durability. While innovations such as 3-dimensional electroanatomic mapping systems and intracardiac echocardiography can enhance procedural precision in catheter ablation, fluoroscopy remains the primary imaging modality for guiding pentaspline PFA in many electrophysiology labs worldwide. This is particularly true in centers where limitations in cost, infrastructure, or training may preclude the routine use of advanced imaging technologies. This article summarizes general practical considerations and presents a primarily fluoroscopy-based, refined workflow developed by a group of experts. The goal is to provide a procedural foundation and practical guide for using the pentaspline FARAPULSE PFA system in atrial fibrillation ablation procedures. Developing a fluoroscopy-based practical guide would: (1) Democratize access to PFA technology, enabling safe and effective implementation across a broader range of clinical settings, including those without intracardiac echocardiography or 3-dimensional mapping support; (2) Reduce procedural heterogeneity by offering reproducible best practices; (3) Facilitate meaningful intercenter comparisons of procedural efficacy and safety, aiding in the identification of optimal approaches and improving the quality of clinical data for ongoing research, registries, and real-world performance monitoring of PFA technologies; and (4) Ultimately improve patient outcomes through standardized, accessible, and evidence-based practices.

Aims: Pulsed field ablation (PFA) has rapidly emerged as a non-thermal ablation technology for pulmonary vein isolation (PVI), with an unprecedented adoption across Europe. The aim of this survey was to characterize current practice patterns. Methods and results: The European Heart Rhythm Association (EHRA) Scientific Initiatives Committee designed a 30-item questionnaire addressing temporal adoption of PFA, pre-, intra-, and post-procedural workflows, and future perspectives. The survey was distributed between April and June 2025. A total of 216 responses were obtained from 43 countries. At the time of the survey, 23% of respondents had not yet initiated a PFA programme. Overall, PFA is now used in half (49%) of first atrial fibrillation (AF) ablation procedures. Adoption was significantly higher in high-volume centres and ‘Western European’ countries. The primary driver for adoption was time efficiency (60%). Intra-procedural workflows showed marked heterogeneity: approximately half of the operators relied exclusively on fluoroscopy without any intra-procedural imaging/mapping. Additional ablation lesions beyond PVI were common, with one-third employing standardized PVI+ protocols in persistent AF, most frequently posterior wall isolation. General anaesthesia and deep sedation were used in equal proportions. Conclusion: This EHRA survey demonstrates both rapid implementation and significant heterogeneity in PFA use across Europe. Standardized protocols and prospective studies are needed to define best practices.

Advanced ablation strategies are needed to treat ventricular tachycardia (VT) and premature ventricular complexes (PVC) refractory to standard unipolar radiofrequency ablation (Uni-RFA). Bipolar radiofrequency catheter ablation (Bi-RFA) has emerged as a treatment option for refractory VT and PVC. Multicentre registry data on the use of Bi-RFA in the setting of refractory VT and PVC are lacking. The aim of this Bi-RFA registry is to determine its real-world safety, feasibility, and efficacy in patients with refractory VT/PVC. Consecutive patients undergoing Bi-RFA at 16 European centres for recurring VT/PVC after at least one standard Uni-RFA were included. Second ablation catheter was used instead of a dispersive patch and was positioned at the opposite site of the ablation target. Between March 2021 and August 2024, 91 patients underwent 94 Bi-RFA procedures (74 males, age 62 ± 13, and prior Uni-RFA range 1–8). Indications were recurrence of PVC (n = 56), VT (n = 20), electrical storm (n = 13), or PVC-triggered ventricular fibrillation (n = 2). Procedural time was 160 ± 73 min, Bi-RFA time 426 ± 286 s, and mean Uni-RFA time 819 ± 697 s. Elimination of clinical VT/PVC was achieved in 67 (74%) patients and suppression of VT/PVC in a further 10 (11%) patients. In the remaining 14 patients (15%), no effect on VT/PVC was observed. Three major complications occurred: coronary artery occlusion, atrioventricular block, and arteriovenous fistula. Follow-up lasted 7 ± 8 months. Nineteen patients (61%) remained VT free. ≥80% PVC burden reduction was achieved in 45 (78%). These real-world registry data indicate that Bi-RFA appears safe, is feasible, and is effective in the majority of patients with VT/PVC.