Aims: Ablation modalities differ in their mechanisms of action, tissue specificity, and collateral effects—particularly on the cardiac autonomic nervous system. This study aimed to compare the autonomic effects of pulsed field ablation (PFA) vs. thermal ablation (TA) in patients with atrial fibrillation (AF) through a pooled analysis. Methods and results: A systematic search of PubMed and Embase was conducted through 5 April 2025, to identify comparative studies. The primary outcome was increase in heart rate (IHR) after ablation, and the secondary outcome was increase in serum S100B (IS100B), a marker of neural injury. Eight studies involving 1007 AF patients were included (mean age: 63.39 ± 10.75 years; 36.3% female; maximum follow-up: 12 months). Baseline characteristics, including the use of antiarrhythmic drugs, were similar between the PFA and TA groups. Pooled analysis showed that PFA was associated with a significantly lower IHR compared to TA (PFA: 4.41 ± 8.86 bpm vs. TA: 10.81 ± 10.46 bpm; P < 0.00001). This difference persisted at midterm (3–6 months) and long-term (12 months) follow-up and remained consistent across age, sex, and different TA modalities (cryoballoon vs. radiofrequency). Correspondingly, the IS100B was significantly less pronounced after PFA (PFA: 33.27 ± 9.46 pg/mL vs. TA: 97.53 ± 31.88 pg/mL; P < 0.00001). Conclusion: PFA-based pulmonary vein isolation in patients with AF results in a smaller post-procedural IHR and less S100B release, suggesting reduced neural damage and less disruption of the autonomic nervous system compared to TA. These effects are sustained through mid- to long-term follow-up and may have potential implications for patient selection and individualized ablation strategies.

This technical report presents a compelling case for the use of very-high-power, very-short-duration (VHPSD) radiofrequency ablation as a promising and efficient strategy for treating symptomatic premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT). The patient with frequent, symptomatic PVCs and a 24% burden underwent successful ablation using a 90 W/4 s recipe via the QDOT MICRO™ catheter. The procedure resulted in immediate and sustained elimination of PVCs, with only 4 s of ablation time, near-zero fluoroscopy, no complications, and no PVC recurrence at 6 months. VHPSD ablation, though originally developed for atrial fibrillation, demonstrated remarkable procedural efficiency, precision, and lesion efficacy in this case. Compared to standard power, long-duration (SPLD) ablation, VHPSD offers the potential to significantly reduce procedural time, minimize tissue edema, and lower complication risk, particularly advantageous in anatomically challenging areas or in situations where maintaining stable catheter contact for extended periods is difficult or unfeasible. This technical report suggests the transformative potential of VHPSD as a first-line ablation strategy for RVOT-PVCs, provided careful mapping and appropriate technique are used. It underscores the need for further prospective studies to validate its broader safety, efficacy, and role in PVC management, particularly in cases involving intramural origins.