Background/Objectives: Cardiac resynchronization therapy with defibrillator (CRT-D) is a well-established therapy for patients with heart failure (HF) and intraventricular conduction delays, but a non-negligible risk of infection and of lead functionality loss overtime is related to intravascular hardware. The novel DX system enables atrial sensing through a floating dipole integrated into the ICD lead, reducing the intravascular burden. In this prospective non-randomized study, we aimed to evaluate the safety and efficacy of a two-lead DX-based CRT system compared to a conventional three-lead (3L) CRT-D system. Methods: A total of 210 patients meeting CRT indications and no signs of sick sinus syndrome (SSS) (baseline HR ≥ 45 bpm, or at least 85 bpm at 6 min walking test) were enrolled. Patients were assigned to either the CRT-DX or conventional 3L CRT-D group. The primary endpoint was a composite clinical response, defined as the freedom from cardiovascular death, HF hospitalization, or new-onset atrial fibrillation (AF). Results: After a mean follow-up of 46.5 ± 1.9 months, both groups had comparable clinical and instrumental outcomes. CRT-DX patients exhibited higher atrial sensing amplitudes and no significant differences in loss of lead function. Conclusions: In conclusion, the CRT-DX system provides equivalent clinical and echocardiographic benefits compared to conventional CRT-D in patients without an indication for atrial pacing. This supports the use of the DX system as a safe and effective alternative in the majority of CRT recipients.

Atrial fibrillation (AF) management has historically relied on thermal ablation modalities—radiofrequency (RF) and cryoballoon—which have established a high benchmark for pulmonary vein isolation (PVI). However, the inherent risk of collateral thermal injury and lesion inconsistency has driven the search for alternative energy sources. The recent clinical adoption of pulsed-field ablation (PFA), based on irreversible electroporation, represents a significant technological evolution. This narrative review provides a critical appraisal of the transition from thermal to pulsed-field technologies. We synthesized data from pivotal trials and recent health-economic analyses to evaluate the biophysical mechanisms, clinical efficacy, and safety profiles of contemporary devices. We conduct a head-to-head comparison of all modalities regarding critical safety endpoints (esophageal, neurological, and vascular), real-world procedural challenges (anesthesia, lesion assessment), and economic sustainability. While PFA offers distinct advantages in procedural speed and tissue selectivity, we highlight that thermal modalities—particularly cryoballoon and very-high-power RF—retain competitive profiles in terms of cost-effectiveness and established long-term durability. This review aims to provide a balanced roadmap for clinicians navigating the complex choice between established thermal efficacy and the promising, yet evolving, landscape of electroporation.