Pulsed Field Ablation for Ventricular Tachycardia: A Systematic Review and Exploratory Bayesian Meta-Analysis of Non-Randomized Studies

Pulsed Field Ablation for Ventricular Tachycardia: A Systematic Review and Exploratory Bayesian Meta-Analysis of Non-Randomized Studies | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 19 September 2025 V1 Latest version Share on Pulsed Field Ablation for Ventricular Tachycardia: A Systematic Review and Exploratory Bayesian Meta-Analysis of Non-Randomized Studies Authors : Faizan Abbas 0009-0005-5176-1680 [email protected] , Aniq Saleem , Johar Raza , Muhammad Hamza Rana , Hazem Abozguia , and Khalid Abozguia Authors Info & Affiliations https://doi.org/10.22541/au.175828522.23936840/v1 472 views 165 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background Pulsed field ablation (PFA) is an established modality for atrial fibrillation (AF) due to myocardial selectivity and reduced collateral injury. Its role in ventricular tachycardia (VT) remains uncertain, with evidence limited to case reports and small series. Methods We searched PubMed, Scopus, and Cochrane without date or language restrictions for peer‐reviewed studies reporting original clinical data on PFA for VT, alone or with radiofrequency ablation (RFA). Eligible designs included case reports, case series with patient‐level data, observational studies, and randomized trials reporting acute procedural success or VT recurrence. Non‐clinical studies, grey literature, and reports without procedural outcomes or clear ablation strategy were excluded. Data were synthesized using Bayesian hierarchical meta‐analysis with a binomial likelihood and logit link. Publication bias was assessed using a Bayesian analogue of Egger’s test. Quality was appraised with Joanna Briggs Institute checklists and the Methodological Index for Non‐Randomized Studies. Results Twenty studies (2 observational, 6 case series, 12 case reports) comprising 71 patients met inclusion. PFA alone was performed in 27 cases (38%) and PFA+RFA in 44 (62%). Pooled acute procedural success was 90.1% (95% Credibility Interval(CrI) (82.7–94.9%), and VT recurrence occurred in 24.8% (95% CrI: 13.7–37.8%). Complications occurred in 12 patients (16.9%); no post‐procedural adverse events were reported during follow‐up in 70 cases (98.5%). Conclusion PFA appears feasible for VT ablation but current evidence is limited. Larger, methodologically rigorous studies with standardized outcomes and direct comparisons to existing therapies are warranted. Keywords: Pulsed field Ablation; Radiofrequency Ablation; Mapping system; Ventricular tachycardia; Electrophysiology Title: Pulsed Field Ablation for Ventricular Tachycardia: A Systematic Review and Exploratory Bayesian Meta-Analysis of Non-Randomized Studies Short title: PFA for Ventricular Tachycardia Authors and Affiliations: Faizan Abbas, MBBS, MD, BSc¹* Aniq Saleem, MBBS, MD, BSc¹ Johar Raza, MBBS, MD² Muhammad Hamza Rana, MBBS, MD³ Hazem Abozguia⁴ Khalid Abozguia, MD, PhD⁵ ¹ Department of Medicine, Fatima Memorial Hospital, Lahore, Pakistan ² Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan ³ Department of Medicine, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania, USA ⁴ Undergraduate Student, Department of Biology and Department of Biochemistry, Marshall University, Huntington, West Virginia, USA ⁵ Department of Cardiovascular Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA *Corresponding Author: Faizan Abbas, MBBS, MD, BSc Department of Medicine, Fatima Memorial Hospital Shadman Road, Lahore, Pakistan Email: [email protected] Statements and Declarations The authors declare that they were not loaned or given any equipment, materials, or medication for this study; did not receive funding to support the research; were not provided with honoraria, payments, or other compensation; did not receive stock options, stock ownership, or other valuable materials; and did not receive outside financial support for travel or lectures to present the study findings. The authors have no financial relationships with any entity that may compete with the medications, materials, or instruments covered in this study, and have neither ownership of nor applications for patents related to them. No author receives compensation for any therapy discussed in the article, and no author has immediate family members with a conflict of interest as defined above. AM Active Mapping ICD Implantable Cardioverter Defibrillator ICM Ischemic Cardiomyopathy LV Left Ventricular PFA Pulsed Field Ablation PM Pace Mapping RFA Radiofrequency Ablation SM Substrate Mapping VT Ventricular Tachycardia 1. Introduction Catheter-based interventions have become a cornerstone in the management of ventricular arrhythmias, providing therapeutic benefit across a range of arrhythmic substrates [1]. In individuals with structural heart disease experiencing sustained ventricular tachycardia (VT), catheter ablation has demonstrated the ability to reduce implantable cardioverter-defibrillator (ICD) interventions, minimize arrhythmia-related hospital admissions, and may even contribute to improved long-term survival [2, 3]. Historically, radiofrequency (RF) energy has served as the foundational modality for ablating recurrent ventricular arrhythmias [4]. Despite its clinical utility, traditional RF ablation is constrained by limitations. The small and discrete lesion footprint may be insufficient for broader arrhythmic substrates, and the procedure often necessitates high-volume saline irrigation, introducing the risk of volume overload [5, 6]. Additionally, in regions characterized by myocardial scarring or difficult-to-access areas such as the papillary muscles and left ventricular (LV) summit, RF may be unable to achieve adequate lesion depth [5–7]. Other procedural hazards include overheating of tissue and steam pop formation, which can result in severe complications such as embolic stroke or cardiac rupture [8–10]. These challenges underscore the need for innovative technologies that not only address the shortcomings of RF ablation but also retain or exceed its efficacy. One such emerging modality is pulsed field ablation (PFA), a nonthermal technique that delivers high-voltage, short-duration electrical pulses to induce irreversible electroporation, enabling the formation of deep, durable lesions within myocardial tissue while selectively sparing adjacent structures such as endothelium, arterioles, nerve fascicles, and pericardial tissue even in infarcted ventricular substrates [11–14]. PFA is capable of generating transmural lesions with uniformity, without the risk of scar contraction or coagulum formation [14]. Its nonthermal nature reduces thromboembolic risks associated with heat-based energy delivery and allows for rapid lesion creation, potentially improving catheter stability and reducing procedural times [11]. Although the clinical use of PFA for ventricular tachycardia (VT) remains limited, preclinical studies, particularly those conducted in swine models, have demonstrated promising efficacy and safety profiles. At present, human data supporting ventricular PFA are confined to isolated case reports(CR)[14–27] and small case series (CS) [11, 28–32], offering only preliminary insight into its clinical utility. In this systematic review and meta-analysis, we aim to consolidate the current body of evidence on the use of PFA for VT, with a focus on procedural success rates, intra- and post-procedural complications, and arrhythmia recurrence following ablation. By summarizing the available data, this review seeks to inform ongoing clinical evaluation and provide a foundation for future randomized controlled trials (RCT’s) and large-scale observational studies assessing the role of PFA in the treatment of VT. 2. Methodology 2.1. Protocol and registration The protocol for this systematic review and Bayesian hierarchical random-effects meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO) [33] under the registration number CRD420251110953 in July 2025. The conduct and reporting of the review followed the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Intervention [34] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [35]. (Supplemental Methods 1 and 2) 2.2. Search strategy and Data extraction A systematic search of the PubMed, Scopus and Cochrane Library databases was conducted in July 2025. Two reviewers (F.A. and A.S.) independently screened the records using Rayyan software [36] in a blinded, dual-review process. Data extraction was also performed independently and in a blinded fashion by the same reviewers. Any discrepancies were resolved through discussion with a third reviewer (M.H.). A detailed description of the search strategy and data extraction process is available in Supplemental Methods 3. 2.3. Eligibility criteria There were no limitations based on the date of publication or language. Studies were deemed eligible for inclusion if they fulfilled all of the following criteria: (1) They consisted of peer-reviewed publications encompassing original clinical data, including case reports, case series, research letters with patient-level data, observational studies (retrospective or prospective), or randomized controlled trials (RCTs); (2) They investigated the use of PFA, either as a standalone technique or in conjunction with radiofrequency ablation (RFA), for the management of ventricular tachycardia (VT); and (3) They provided data relevant to the predefined primary outcome of interest. We excluded editorials, letters to the editor, animal studies, grey literature, studies that did not report procedural outcomes or VT recurrence and studies in which the ablation strategy could not be clearly determined, thereby precluding accurate data extraction. 2.4. End Points The primary outcomes assessed were acute procedural success and the recurrence of ventricular tachycardia during follow-up. Secondary endpoints included the type of ablation catheter used, mapping system employed, duration of follow-up, mapping approach (activation, substrate, or pace mapping), and ablation strategy (endocardial, epicardial, or combined endo-epicardial). A comprehensive definition of all outcomes is available in Supplemental Methods 4. 2.5. Quality Assessment Study quality was evaluated using validated, design-specific tools. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports and the JBI Checklist for Case Series were used for corresponding study types [37, 38]. For observational studies, the Methodological Index for Non-Randomized Studies (MINORS) was applied [39]. Full details are provided in Supplemental Methods 5. 2.6. Statistical Analysis We performed a Bayesian hierarchical meta-analysis with a binomial likelihood and logit link to estimate pooled proportions for binary outcomes, including acute procedural success and post-procedural arrhythmia recurrence. This approach was selected over a traditional frequentist approach due to small sample sizes, extreme event rates, and the need for flexible modeling of uncertainty and between-study heterogeneity [40–42]. Event rates were modeled on the log-odds scale and summarized as posterior means with 95% credible intervals (CrIs). A random-effects structure accounted for heterogeneity, assessed via the posterior distribution of the between-study standard deviation (τ). Weakly informative priors (0, 1) were applied to stabilize estimation in the context of sparse data. To ensure the robustness of the model, we conducted comprehensive diagnostics, detailed in Supplemental Methods 6, including leave-one-out cross-validation (LOO-CV), and assessment of between-study heterogeneity (τ). All diagnostics were satisfactory. Bayesian meta-regression adjusting for study design and ablation type (PFA-only vs PFA+RFA) for both acute procedural success and arrhythmia recurrence outcomes was performed. Secondary outcomes were summarized using descriptive statistics. When applicable, proportions were calculated by dividing the number of events by the total sample size across studies. In other cases, outcomes were reported as the number of studies describing a given characteristic. 2.7. Subgroup and Sensitivity analysis Subgroup analyses were conducted based on study design (observational studies compared with case reports) and ablation strategy (PFA compared with PFA+RFA). Sensitivity analysis was conducted using a leave-one-out approach to assess the robustness of the pooled estimates [43]. 2.8. Publication Bias Publication bias was assessed using a Bayesian analogue of Egger’s test [44], with the standard error of the success proportion used as a proxy for study precision to detect small-study effects [44]. Full details are provided in Supplemental Methods 7. 3. Results A total of 254 articles were initially identified through the database search. After removing duplicate records, 128 unique citations remained and were screened based on their titles and abstracts. Of these, 34 articles were deemed potentially eligible and were subjected to full-text review. Ultimately, 20 studies comprising 2 observational studies, 12 case reports, and 6 case series encompassing 71 individual patients met the predefined inclusion criteria and were included in the final analysis. Of these, 34 cases (48%) originated from observational studies and 37 cases (52%) from case reports and series. The mean age of participants was 62.4 ± 14.5 years, and 58 (82%) were male. PFA alone was performed in 27 cases (38%), while a PFA + RFA approach was employed in 44 cases (62%). The weighted mean follow-up duration per patient was 142.8 ± 63.0 days in case reports and case series, and 152.9 ± 53.3 days in observational studies. A detailed overview of the selection process is provided in the PRISMA flow diagram (Figure 1), and additional baseline and study-level characteristics are summarized in Table 1 . Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram illustrating the process of study selection This is a caption Table 1. Baseline patient and study characteristics of included studies Description: This table summarizes key baseline demographic and clinical characteristics, as well as study-level details. For each study, the design, country of origin, and sample size are reported, along with the mean or median patient age and proportion of male participants. Device-related factors include the presence of an implantable cardioverter-defibrillator (ICD). Clinical history factors include a history of previous ablation procedures and the presence of ischemic cardiomyopathy (ICM). Follow-up duration is expressed in days, reflecting the observation period for each study. Krause et al. (2023) CR Germany 1 33 1 (100%) 1 (100%) 1 (100%) NA 90 Steyer et al. (2024) CR Germany 1 75 1 (100%) 1 (100%) 1 (100%) NA 17 Weyand et al. (2023) CR Germany 1 61 1 (100%) 1 (100%) 0 (0%) NA NA Ollitrault et al. (2025) CR France 1 53 0 0 0 (0%) 1 (100%) 240 Yokoyama et al. (2025) CR France 1 33 1 (100%) 1 (100%) 1 (100%) NA 90 Ouss et al. (2022) CR Netherlands 1 69 1 (100%) 1 (100%) 1 (100%) NA 180 Mannion et al. (2025) CR Ireland 1 60 1 (100%) 1 (100%) 0 (0%) 1 (100%) 90 Adragao et al. (2023) CR Portugal 1 60 1 (100%) 1 (100%) 1 (100%) 1 (100%) 2 Aguilera et al. (2024) CR USA 1 74 1 (100%) 1 (100%) 1 (100%) 1 (100%) 120 Martin et al. (2023) CR UK 1 68 1 (100%) 1 (100%) 1 (100%) 1 (100%) 60 Katrapati et al. (2024) CR USA 1 70 0 1 (100%) 1 (100%) 1 (100%) 72 Cespón-Fernández et al. (2024) CR Belgium 1 60 1 (100%) 1 (100%) 1 (100%) 0 180 Fassini et al. (2024) CS Italy 2 68 ± 6 2 (100%) NA 2(100%) 2(100%) 180 Prajapati et al. (2025) CS USA 2 69 ± 10 2 (100%) 2(100%) 0 (0%) 2(100%) 90 Younis et al. (2025)* CS USA 9 70 ± 7 9 (100%) 9(82%)† 7(78%) 7(78%) 212 ± 56 Lozano-Granero et al. (2023) CS Spain 3 78 ± 8 2 (66.7%) NA 1(33%) NA 150 ± 30 Pannone et al. (2024) RL Belgium 4 56 ± 19 4 (100%) 3 (75%) 3(75%) 1(25%) 150 ‡ Peichl et al. (2024)* PC Czechia 23 63 ± 15 18 (78.3%) NA 17 (74%) NA 116 ± 75 Ruwald et al. (2025)* PC Denmark 11 59 ± 13 8 (72.7%) 9(82%) 4(36%) 6 (55%) 230 ± 132 Padisak et al. (2025) CS Hungary 5 51 ± 14 3 (60%) 5 (100%) 5 (100%) 2 (40%) 106 ± 58 Data are presented as number (%) for categorical variables and as mean ± SD or median (minimum–maximum) for continuous variables, unless otherwise specified. CR = case report; CS = case series; ICD = implantable cardioverter defibrillator; ICM = ischemic cardiomyopathy; NA = not available; PC = prospective cohort; RL = research letter; SD = standard deviation; Hx = history *Only patients with VT are considered. †includes PVC patients, ‡ Median 3.1 Acute Procedural Success 3.1.1 Overall Pooled Estimate The overall pooled probability of acute procedural success across all procedures involving both PFA only and PFA + RFA, was estimated at 90.1% (95% CrI: 82.7% to 94.9%). This high baseline indicates that, across diverse clinical settings, PFA achieves technical success in the vast majority of cases. 3.1.2 Unadjusted Subgroup Analysis We first estimated success probabilities separately for study design and ablation strategy, without adjustment for other factors. In case-based reports, the posterior probability of success was 93.8% (95% CrI: 85.7% to 97.6%). Observational studies showed lower unadjusted estimates, 75.1% (95% CrI: 50%.5 to 88.2%). PFA + RFA yielded 88% (95% CrI: 77.0% to 94.5%) and PFA only had a probability of 87% (95% CrI: 74.2 to 94.3%) (Figure 2-3; Table 2). These stratified results reflect each subgroup’s independent performance; they do not test differences between groups. Between-study heterogeneity, expressed as the posterior standard deviation of study-level effects (τ), was moderate across all groups (τ range: 0.42 to 0.54), supporting the use of partial pooling in subsequent hierarchical models. 3.1.3 Univariable Meta-Regression Next, we conducted two univariable Bayesian meta-regressions, each adjusting for a single covariate while borrowing strength across studies (shrinkage). Adjusting for study design, the observational subgroup estimate increased from 75.1% unadjusted to 84.7% (95% CrI: 69.4% to 95.1%), illustrating shrinkage toward the overall mean. Case-based studies were predicted at 92.1% (83.7% to 97.2%). The log-odds difference (observational vs. case-based) was –0.74 (95% CrI: –1.77 to 0.32), corresponding to an absolute Δ of –7.4 percentage point (pp), however residual uncertainty (Δ 95% CrI: -23.4pp to +4.6pp) remains too large for definitive conclusions. Adjusting for ablation strategy, predicted success was 89.3 % (95% CrI: 77.0% to 96.9% ) for PFA only and 89.6% (95% CrI: 79.1% to 96.5%) for PFA plus RFA, with log-odds difference 0.00 (95% CrI: –1.07 to 1.11) or Δ +0.3pp (95% CrI: –14.5pp to +16.5pp), also inconclusive (Table 2). 3.1.4 Full Multivariable Meta-Regression In a single Bayesian model adjusting jointly for study design, ablation strategy, and sample size (z-score), the reference scenario - PFA only, case-based, average sample size-yielded a 91.8% (80.2% to 97.9%) probability of success. Other subgroup predictions ranged from 86.4% to 93.0%. Covariate effects were inconclusive given credible intervals spanning clinically relevant ranges, observational versus case-based studies showed an absolute Δ of -5.3 pp (95% CrI: -31.0 to 8.5pp), while PFA plus RFA compared to PFA-only yielded a Δ of +1.2 pp (95% CrI: –9.9 to 12.2 pp) (Table 2). Table 2. Bayesian estimates of procedural success by analysis level and group Description: Results from unadjusted subgroup models, univariable meta-regressions, and the full multivariable meta-regression are presented. Posterior probability estimates and absolute probability differences (Δ) are shown with 95 percent CrIs. Δ indicates the change in success probability corresponding to the log-odds difference; values labeled “inconclusive” have CrIs that include both clinically meaningful benefit (>+10 percent) and detriment (<–10 percent). Unadjusted Subgroup Case-Based studies 93.8% (85.7% to 97.6%) — PFA + RFA 88.0% (77.0% to 94.5%) — Observational studies 75.1% (50.5% to 88.2%) — PFA-only 87% (74.2% to 94.3%). — Univariable: Study Design Observational vs. Case-Based 84.7% (69.4% to 95.1%) vs. 92.1% (83.7% to 97.2%) –7.4pp (–27.8pp to 11.4pp), inconclusive Univariable: Ablation Strategy PFA + RFA vs. PFA only 89.6%% (79.1% to 96.5%) vs 89.3% (77.0% to 96.9%) +0.2 pp (–13.1 to 11.7 pp), Inconclusive Full Multivariable Observational vs. Case-Based 86.4% (58.6% to 98.3%) vs. 91.8% (80.2% to 97.9%) -5.3 pp (–31.0 to 8.5pp), inconclusive PFA + RFA vs. PFA only 93.0 (81.6% to 98.5%) vs 91.8% (80.2% to 97.9%) +1.2 pp ( –9.4 to 12.2 pp), inconclusive Sample Size (per SD increase) 93.1% (81.3% to 99.3%) –1.6 pp (-9.4 to 3.3 pp), inconclusive Figure 2. Forest Plot of Posterior Log-Odds for Acute Success Stratified by Study Design Description: This forest plot displays the posterior mean log-odds and corresponding 95% credible intervals (CrIs) for acute success, estimated from a Bayesian hierarchical model. Each dot (●) represents the estimate for an individual study, while each diamond(◆) represents the subtotal estimate for a study design subgroup (Observational or Case-Based). The horizontal lines indicate 95% CrIs derived from the posterior distribution, reflecting the uncertainty around each estimate. Estimates are presented on the log-odds scale to maintain consistency with the modeling approach. Positive values correspond to higher odds of acute success, while negative values indicate lower odds. Subgroup estimates (diamonds) are based on the posterior of the model intercept for each group. Figure 3. Forest Plot of Posterior Log-Odds for Acute Success Stratified by Ablation Type Description: This forest plot presents the posterior mean log-odds and associated 95% credible intervals (CrIs) for arrhythmia recurrence, derived from a Bayesian hierarchical model. Each ● black dot represents the estimate for an individual study, while each ◆ blue diamond corresponds to the pooled (subtotal) estimate for the respective ablation group: PFA-only and Hybrid (combined PFA + RFA). The horizontal lines represent 95% CrIs, indicating uncertainty in each posterior estimate. Estimates are plotted on the log odds scale, where values less than zero suggest a lower probability of recurrence, and values greater than zero suggest a higher probability. Subgroup-level estimates provide pooled summaries based on the posterior distribution of group-level intercepts Subgroup-level estimates provide pooled summaries based on the posterior distribution of group-level intercepts 3.2. Ventricular Tachycardia Recurrence 3.2.1 Overall Pooled Estimate The pooled posterior probability of VT recurrence after ablation was 24.8% (95% CrI: 13.7% to 37.8%), defining the baseline clinical recurrence risk with current PFA practice. 3.2.2 Unadjusted Subgroup Analysis Stratified models estimated each subgroup’s independent recurrence risk: 16.4% (95% CrI: 8.5% to 28.4%) in case-based studies, 50.6% (95% CrI: 31.6% to 69.0%) in observational studies, 27.5% (95% CrI: 14.0% to 44.4%) for hybrid PFA + RFA, and 27.5% (13.7% to 45.2%) for PFA-only (Figure 4&5; Table 3). Between-study heterogeneity was moderate to substantial across subgroups: τ = 0.741 (95% CrI: 0.028 to 2.27) for PFA-only, τ = 0.915 (0.035 to 2.75) for hybrid ablation, and τ = 0.428 (0.027 to 1.16) for the overall model by study design. These values support the need for hierarchical modeling to account for variability in recurrence outcomes 3.2.3 Univariable Meta-Regression Adjusting only for study design, case-based recurrence remained 19.9% (95% CrI: 9.6% – 33.2%) while observational studies recurrence was 44.2% (95% CrI: 21.1% – 64.5%). The log-odds difference of 1.19 (95% CrI: 0.27 to 2.07) corresponds to Δ +24.3 pp (95% CrI:1.38 to 46.0 pp) (Table 3). While this excludes zero, the extreme width (+44.6% pp) and failure to exclude clinically trivial effects (lower bound Δ+1.4 pp) preclude definitive claims. In the ablation strategy model, recurrence probabilities were nearly identical, 24.8% (95% CrI: 8.8% – 44.2%) for PFA only and 25.7% (95% CrI: 9.6% – 44.6%) for PFA + RFA, log-odds difference 0.04 (95% CrI: –1.08 to 0.981), Δ 0.68 pp (95% CrI: –22.4 to +21.8 pp).In the ablation strategy model, recurrence probabilities were nearly identical: 24.8% (95% CrI: 8.8% to 44.2%) for PFA only and 25.7% (95% CrI: 9.6% to 44.6%) for PFA plus RFA. The estimated log-odds difference was 0.04 (95% CrI: –1.08 to 0.98), corresponding to an absolute Δ of 0.8 pp (–21.4 to +22.8 pp). While uncertainty remains high, this finding contributes by suggesting no meaningful difference in recurrence risk between the two strategies. 3.2.4 Full Multivariable Meta-Regression‘ The fully adjusted model predicted recurrence of 20.6% (95% CrI: 7.5% to 39.3%) in the reference scenario. Other subgroup estimates ranged from 17.5% to 35.4%. Covariate effects were inconclusive given credible intervals spanning clinically relevant ranges: observational versus case-based studies showed an absolute difference (Δ) of +14.9 pp (95% CrI: –13.0 to +49.6 pp), while hybrid PFA plus radiofrequency ablation versus PFA-only yielded a Δ of –3.1 pp (95% CrI:–22.1 to +16.1 pp) (Table 3). Table 3. Bayesian estimates of VT recurrence by analysis level and group Description: This table summarizes unadjusted subgroup recurrence risks, univariable meta-regression comparisons, and fully adjusted multivariable meta-regression results. Δ indicates the absolute difference in recurrence probability corresponding to the log-odds difference. Values labeled “excludes zero” are credible, while those spanning thresholds of clinical relevance are inconclusive. Unadjusted Subgroup Case-Based 16.4% (8.5 to 28.4%) — Observational studies 50.6% (31.6 to 69.0%) — PFA+RFA 27.5% (14.0 to 44.4%) — PFA 27.5% (13.7 to 45.2%) — Univariable: Study Design Observational vs. Case-Based 44.2% ( 21.1% to 64.5%) vs. 19.9% (9.6% – 33.2%) +24.3 pp (1.38 to 46.0 pp), excludes zero Univariable: Ablation Strategy PFA + RFA vs. PFA only 25.7% (9.6% to 44.6%)vs 24.8% (8.8% to 44.2%) 0.68 pp(–22.4 to +21.8 pp), Inconclusive Full Multivariable Observational vs. Case-Based 35.4% (7.8% to 71.2%) vs. 20.6% (7.5% to 39.3%) 14.9 pp (–13.0 to +49.6 pp), inconclusive PFA + RFA vs. PFA only 17.5% (6% to 35.2%) vs. 20.6% (7.5% to 39.3%) –3.1 pp (–22.1 to +16.1 pp), inconclusive Sample Size (per SD increase) 20.9% (7.56% to 39.8%) +4.1 pp (–5.0 to +16.3 pp), inconclusive Figure 4. Forest Plot of Posterior Log-Odds for Arrhythmia Recurrence by study design Description: This forest plot displays the posterior mean log-odds and corresponding 95% credible intervals (CrIs) for arrythmia recurrence, estimated from a Bayesian hierarchical model. Each dot (●) represents the estimate for an individual study, while each diamond(◆) represents the subtotal estimate for a study design subgroup (Observational or Case-Based). The horizontal lines indicate 95% CrIs derived from the posterior distribution, reflecting the uncertainty around each estimate. Estimates are presented on the log-odds scale to maintain consistency with the modeling approach. Positive values correspond to higher odds of acute success, while negative values indicate lower odds. Subgroup estimates (diamonds) are based on the posterior of the model intercept for each group. Figure 5. Forest Plot of Posterior Log-Odds for Arrythmia Recurrence Stratified by Ablation Type Description : This forest plot presents the posterior mean log-odds and associated 95% credible intervals (CrIs) for arrhythmia recurrence, derived from a Bayesian hierarchical model. Each ● black dot represents the estimate for an individual study, while each ◆ blue diamond corresponds to the pooled (subtotal) estimate for the respective ablation group: PFA-only and Hybrid (combined PFA + RFA). The horizontal lines represent 95% CrIs, indicating uncertainty in each posterior estimate. Estimates are plotted on the log-odds scale, where values less than zero suggest a lower probability of recurrence, and values greater than zero suggest a higher probability. Subgroup-level estimates provide pooled summaries based on the posterior distribution of group-level intercepts 3.3. Procedural characteristics The endocardial approach was the predominant ablation strategy, utilized in 66 cases (92.9%), followed by combined endo-epicardial in 3 cases (4.2%) and epicardial-only in 2 cases (2.8%). Regarding mapping systems, CARTO 3 was used in six studies, AFFERA in five, EnSite in three, and Rhythmia in one. One study reported using both CARTO 3 and EnSite. The FARAWAVE catheter was the most commonly used ablation device (11 studies), followed by the Sphere-9 catheter in 5 studies and ThermoCool SmartTouch in 3. In terms of mapping techniques, activation mapping was conducted in 50 cases (70.4%), pace mapping in 47 (66.1%), and substrate mapping in 55 (77.4%). Most procedures were well-tolerated, with only 12 patients (16.9%) experiencing procedural complications. No post-procedural adverse events were reported during follow-up in 70 cases (98.5%). Procedural characteristics are summarized in Table 4. Table 4. Summary of procedural and post-procedural characteristics of included studies Description: The table outlines key technical and clinical details for each included study, including the type of ablation performed (e.g., PFA or PFA+RFA), procedural approach, and application technique. Device-related parameters are summarized, such as the PFA catheter used, the mapping system employed, the mapping catheter type, and the mapping methodology. Procedural complications observed during the intervention and post-procedural complications occurring after the procedure are also reported. [1]¿p#1 Krause et al. PFA Endocardial NA FARAWAVE NA NA PM / SM / AM 0 (0%) 0 (0%) Steyer et al. PFA + RFA Endo-epicardial NA SPHERE 9 AFFERA SPHERE‑9 AM 1 (100%) 1 (100%) Weyand et al. PFA + RFA Endocardial NA TCSM‑C CARTO 3 PENTARAY SM / AM NA 0 (0%) Ollitrault et al. PFA Endocardial FLOWER AND BASKET FARAWAVE NA NA NA NA 0 (0%) Yokoyama et al. PFA Epicardial NA SPHERE 9 AFFERA SPHERE‑9 SM / AM 1 (100%) 0 (0%) Ouss et al. PFA Endocardial NA FARAWAVE NA NA SM / AM 0 (0%) 0 (0%) Mannion et al. PFA + RFA Endocardial NA SPHERE 9 AFFERA SPHERE‑9 SM 0 (0%) 0 (0%) Adragão et al. PFA + RFA Endocardial FLOWERLIKE FARAWAVE CARTO 3 OCTARAY SM / AM 1 (100%) 0 (0%) Aguilera et al. PFA + RFA Endocardial NA SPHERE 9 AFFERA SPHERE‑9 PM / SM / AM 0 (0%) 0 (0%) Martin et al. PFA Endocardial FLOWER AND BASKET FARAWAVE RHYTHMIA ORION SM / AM 0 (0%) 0 (0%) Katrapati et al. PFA Endocardial FLOWER FARAWAVE ENSITE HD GRID SM / AM 0 (0%) 0 (0%) Cespón‑Fernández et al. PFA + RFA Endo-epicardial NA TCSM‑C NA NA PM / SM / AM 1 (100%) 0 (0%) Fassini et al. PFA 1 (50%) PFA + RFA 1 (50%) Endocardial FLOWER FARAWAVE ENSITE HD GRID SM / AM 0 (0%) 0 (0%) Prajapati et al. PFA + RFA 2 (100%) Endocardial NA FARAWAVE ENSITE OPTRELL PM / SM 2 (100%) 0 (0%) Younis et al. PFA 1 (11%) PFA + RFA 8 (89%) Epicardial 1 (11%), Endocardial 8 (89%) FLOWER AND BASKET FARAWAVE CARTO 3 & ENSITE OPTRELL, OCTARAY, HD GRID PM / SM / AM 0 (0%) 0 (0%) Lozano‑Granero et al. PFA 2 (67%) PFA + RFA 1 (33%) Endocardial 2 (66%) Endo-epicardial 1 (33%) BASKET FARAWAVE CARTO 3 PENTARAY PM / SM / AM 0 (0%) 0 (0%) Pannone et al. PFA 1 (25%) PFA + RFA 3 (75%) Endocardial NA SPHERE 9 AFFERA SPHERE‑9 PM / SM / AM 0 (0%) 0 (0%) Peichl et al. PFA and PFA + RFA Endocardial NA TCSM‑C CARTO 3 NA PM / SM / AM 3 (13%) 0 (0%) Ruwald et al. PFA 11 (100%) Endocardial NA NA CARTO 3 OCTARAY PM / SM / AM 3(27%) 0(0%) Padisak et al. PFA 5 (100%) Endocardial FLOWER FARAWAVE CARTO 3 PENTARAY PM / SM / AM 0 (0%) 0 (0%) AM = activation mapping; NA = not available; PFA = pulse field ablation; PM = pace mapping; RFA = radiofrequency ablation; SM = substrate mapping; TSCM-C = ThermoCool SmartTouch with Centauri System. 3.4. Sensitivity analyses Leave-one-out sensitivity analyses were conducted to assess the robustness of the pooled estimates for both acute procedural success and arrhythmia recurrence. For acute success, exclusion of individual studies yielded posterior log-odds ranging from 2.57 to 3.81, with all 95% credible intervals remaining entirely above zero. This indicates consistently high procedural success regardless of which study was omitted. For recurrence, posterior log-odds estimates ranged from –1.19 to –1.69, with all credible intervals remaining entirely below zero across all exclusions. This confirms the stability of the recurrence model, with no single study exerting undue influence on the overall effect. These findings support the robustness and internal consistency of the pooled models. (Supplemental Methods 6) 3.5. Publication Bias For acute procedural success, the estimated slope (β) was 0.03 (95% CrI:–3.88 to 3.93), with a posterior probability of 50.2% that the slope was positive. The corresponding funnel plot showed no major asymmetry, suggesting no strong evidence of publication bias. For recurrence, the estimated slope was similarly close to zero at 0.05 (95% CrI:–3.77 to 3.93), with a posterior probability of 50.7% that the slope was positive. These results indicate no directional trend or substantial asymmetry in the data, supporting the absence of publication bias in either model. While these findings do not support the presence of publication bias, the limited number of observational studies and predominance of case reports/series warrant cautious interpretation. Full details are provided in Supplemental Methods 7. 3.6. Quality Assessment A total of 12 case reports and 6 case series were evaluated. Among the case reports, 7 studies achieved a score of 8/8 and 5 scored 7/8. For the case series, 2 studies received a full score of 10/10, 1 scored 9/10, 2 scored 8/10, and 1 scored 7/10. Overall, these assessments reflect good methodological quality across both study types. Two observational studies were assessed using the MINORS tool. Peichl et al. scored 13/16, and Ruwald et al. scored 12/16, suggesting moderate to high methodological rigor. Full scoring details for the JBI case series and case reports, as well as the MINORS assessments, are presented in Supplemental Method 5. 4. Discussion To the best of our knowledge, this is the first meta-analysis to synthesize outcomes of PFA for VT, incorporating the largest number of patients and studies to date [45]. The following major findings emerged from our analysis: First, results from the multivariable regression of acute success and recurrence were inconclusive, and the current data do not support a preference for either PFA alone or PFA combined with RFA, nor do they establish the superiority of one approach over the other. Second, based on descriptive data, procedures were well-tolerated overall, with few peri-procedural and post-procedural complications observed. Lastly, moderate heterogeneity was observed in the analysis of success outcomes, and moderate to substantial heterogeneity was noted for recurrence reflecting the inherent complexity of real-world variations. The literature on the use of PFA for VT remains in its early stages. In our analysis, the pooled posterior probability of acute procedural success was high at 90.1% (95% CrI: 82.7% to 94.9%). This is comparable to success rates reported in other arrhythmia settings managed with PFA, which range from 82% to 99% depending on the type of arrhythmia, including premature ventricular contractions (PVC), atrial fibrillation (AF), and VT [46–48]. For acute success, adjusting for study design alone, the observational subgroup estimate increased from 75.1% to 84.7%, and further adjustment for ablation strategy and sample size yielded 86.4%. This progressive shift toward the overall mean (90.1%) reflects Bayesian shrinkage, a feature where estimates with high uncertainty are partially pooled toward the global average to mitigate overinterpretation of sparse data. It underscores the importance of interpreting subgroup effects within the context of the full model, rather than relying solely on raw comparisons. Although direct comparisons between arrhythmia types should be approached with caution due to differences in underlying substrates and clinical contexts, our pooled recurrence probability of 24.8% (95% CrI: 13.7% to 37.8%) for VT and fully adjusted 20.6% (95% CrI: 7.5% to 39.3%) in PFA only cases is broadly aligned with recurrence rates reported in atrial arrhythmia populations treated with PFA, which range from approximately 11 to 24 % [49, 50]. In unadjusted analyses, case-based reports showed a 16.4% recurrence rate (95% CrI: 8.5%–28.4%), whereas observational studies reported 50.6% (95% CrI: 31.6%–69.0%). In a meta-regression model including only study design, observational studies had a significantly higher recurrence risk (log-odds difference = 1.19, 95% CrI: 0.27–2.07), corresponding to a Δ of +24.3 pp (95% CrI: +1.4 to +46.0 pp). Although the interval excludes zero, its wide span, ranging from minimally to highly clinically significant, inhibits definitive interpretation. After further adjusting for ablation strategy and sample size, the association attenuated toward the null, suggesting that unmeasured factors may confound the design effect. One plausible explanation for the higher recurrence observed in observational studies is the use of longer or more structured follow-up protocols, which may improve the detection of late recurrences. However, our analysis showed nearly identical weighted mean follow-up durations per patient in case-based studies (142.8 ± 63.0) and observational studies (152.9 ± 53.3days), indicating that follow-up duration alone is unlikely to explain the difference. While patient-level characteristics may have some influence, methodological differences in how outcomes are assessed appear to be the most likely explanation. Features such as prospective data collection, predefined recurrence criteria, and systematic monitoring commonly used in observational cohorts may contribute to higher reported recurrence. In the multivariable analysis of acute success, comparisons between PFA-only and PFA+RFA approaches showed a minimal point estimate (Δ +1.2 pp; 95% CrI: –9.4 to +12.2 pp). The interval width (21.6 percentage points) reflects uncertainty, but the symmetric distribution around zero and near-null effect size support comparable efficacy between approaches. In contrast, for recurrence (Δ –3.1 pp, 95% CrI: –22.1 to +16.1 pp) and study design comparisons for both success (Δ –5.3 pp, 95% CrI: –31.0 to +8.5 pp) and recurrence (Δ +14.9 pp, 95% CrI: –13.0 to +49.6 pp), the credible intervals remained wide, spanning trivial to substantial effects and precluding definitive conclusions. Although all inconclusive, these findings help identify the areas of greatest uncertainty, particularly the influence of study design and recurrence outcomes, and highlight where future research should focus to meaningfully reduce ambiguity. Given comparable efficacy in the multivariable analysis, with no credible difference in acute success (Δ +1.2 percentage points, 95% CrI: –9.4 to +12.2) or recurrence (Δ –3.1 percentage points, 95% CrI: –22.1 to +16.1), PFA alone appears to perform similarly to hybrid ablation. Although these differences remain statistically inconclusive, the findings suggest that PFA-only is a reasonable alternative when guided by clinical judgment. This approach also offers practical advantages, including shorter procedural times, a nonthermal mechanism of action, and potentially fewer peri-procedural complications, which may help reduce physician fatigue, increase procedural throughput, and improve patient access. These benefits should be balanced against the learning curve associated with adopting PFA technology. Overall, the comparable success rates provide clinicians with the flexibility to select ablation strategies based on patient characteristics, procedural complexity, and equipment availability. When operator expertise and clinical context align, PFA-only may represent a viable first-line option for VT ablation. Overall, procedures involving PFA demonstrated a favorable safety profile with 87% procedures without any complication, supporting the existing literature on its safety [51, 52]. Conduction block was reported in four patients [1, 20], and two patients experienced transient circulatory collapse requiring defibrillation [18, 31]. One patient developed a clinically induced VT during ablation requiring cardioversion [31], and another experienced coronary spasm involving the left circumflex artery [15]. Additional nonfatal adverse events included one case of urinary tract bleeding and two vascular access complications [53]. Except for a case of coronary artery laceration with associated pericardial effusion all other intra-procedural events were non-fatal and were managed appropriately without lasting sequelae. Although, the patient with coronary laceration did not experience any recurrence of ventricular tachycardia and showed initial good recovery, he subsequently developed worsening low cardiac output. Despite intensive management, the patient’s condition deteriorated, progressing to acute oliguria on a background of chronic renal failure. The clinical course further evolved into refractory septic cardiomyopathy with progressive multiorgan failure, ultimately resulting in the patient’s death [54]. Postprocedural complications were rare too, consistent with other published literature describing the overall safety and low complication rates associated with PFA [45, 49, 51, 52, 55]. Our hierarchical models revealed moderate between-study heterogeneity for acute procedural success and moderate to substantial heterogeneity for recurrence across subgroups. This variation is likely driven by differences in ablation protocols, patient characteristics, follow-up intensity, and study design. These heterogeneity estimates justify the use of Bayesian hierarchical models with partial pooling. By borrowing strength across studies, the model shrinks extreme study-level estimates toward the overall mean, reducing the influence of small-sample outliers. Despite this, residual heterogeneity persists, suggesting that unmeasured confounders remain. Future studies could help reduce τ by harmonizing ablation techniques, follow-up protocols, incorporating variables such as lesion set, contact force metrics, and monitoring duration may further explain the remaining between-study variability. A previously published systematic review laid important groundwork in highlighting the potential role of PFA for VT. While that review offered valuable early insights, it was primarily descriptive in nature and did not incorporate statistical modeling to explore heterogeneity or effect modifiers. To advance the field, our study aimed to build on these foundations by performing a quantitative synthesis using Bayesian meta-analytic techniques. Additionally, since the publication of the prior review, several new case reports, case series, and observational studies have emerged, which we incorporated to provide a more up-to-date and comprehensive analysis. While the earlier review focused exclusively on PFA, we recognized the increasing use of hybrid ablation strategies involving both PFA and RFA. Accordingly, our approach included all available cases of PFA use in VT, whether standalone or combined, and we adjusted for ablation modality to better understand the contribution of each strategy to clinical outcomes. To date, PFA has primarily been used as a bailout strategy for refractory VT. However, the promising acute success rates and competitive recurrence outcomes observed in this analysis, along with its favorable safety profile, suggest that PFA may have broader applicability as a frontline therapeutic option. Before PFA can be established as a potentially superior modality for the treatment of VT, several critical evidence gaps must be addressed. RCT’s comparing PFA with standard ablation techniques are essential to determine whether its procedural advantages translate into superior clinical outcomes. Future studies should adopt standardized definitions for procedural success and arrhythmia recurrence, ensure consistent reporting of procedural parameters, and include formal assessments of lesion durability. Long-term follow-up will be vital to evaluating sustained efficacy and the risk of late recurrence. Additionally, the clinical value of hybrid ablation strategies requires further clarification, particularly in patients with extensive ventricular scarring. Limitations This review has several limitations. First, the current evidence on PFA for ventricular tachycardia is derived primarily from non-randomized studies, with 52% of patients drawn from single-patient case reports or small series. This introduces a high risk of reporting bias and limits generalizability. While the Bayesian framework allowed for the inclusion of studies with small sample sizes and zero-event data, the overall conclusions remain constrained by the quality and granularity of the available data. We attempted to account for some of these limitations through subgroup and Bayesian meta-regression analyses. Second, the included patient populations often skewed toward highly selected cases, such as those who had failed prior RFA or were treated at specialized centers with early access to PFA technology. These factors may limit generalizability, as patients with prior ablation or advanced cardiomyopathy may respond differently than de novo cases. Moreover, key factors that could influence lesion formation, such as scar age or fibrosis density, were inconsistently reported. Third, significant heterogeneity was observed in how PFA was applied, including variations in catheter design (focal versus multi-electrode), energy delivery protocols, and adjunctive strategies such as standalone PFA versus PFA combined with RFA. While our meta-analysis treated “acute success” and “VT recurrence” in a generalizable manner, the definitions of these outcomes were not uniform across studies. To account for these sources of variability, we employed a Bayesian random-effects meta-analysis, along with subgroup analysis, meta-regression, and sensitivity analyses. Fourth, due to inconsistent and narrative-style reporting in many descriptive studies, several outcomes had to be inferred by the reviewers. This introduces a risk of subjective interpretation, which we sought to minimize through collaborative discussion and consensus resolution. Fifth, many studies reported only short-term outcomes, typically limited to three to six months of follow-up. Given that VT recurrence, particularly in patients with SHD, can occur later due to disease progression or reconnection of incompletely ablated circuits, this limits our understanding of long-term efficacy. Sixth, Funnel plot analysis did not suggest significant asymmetry, although its power was restricted by the small sample size. Therefore, the higher success and lower recurrence rates observed in case-based studies should be interpreted with caution, and greater emphasis should be placed on results from larger, prospective observational studies Conclusion This Bayesian meta-analysis provides a timely aggregation of the new evidence regarding PFA for VT. Although in support of its feasibility, the results call for careful interpretation and reinforce the necessity of forthcoming research with methodologically rigorous design, standardized outcome definition, and head-to-head comparisons with current therapies for VT. Acknowledgement The authors have no acknowledgements to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References 1. 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Turagam MK, Neuzil P, Schmidt B, et al (2023) Safety and Effectiveness of Pulsed Field Ablation to Treat Atrial Fibrillation: One-Year Outcomes From the MANIFEST-PF Registry. Circulation 148:35–46 Tables Table 1 Title : Baseline patient and study characteristics of included studies. Description: This table summarizes key baseline demographic and clinical characteristics, as well as study-level details. For each study, the design, country of origin, and sample size are reported, along with the mean or median patient age and proportion of male participants. Device-related factors include the presence of an implantable cardioverter-defibrillator (ICD). Clinical history factors include a history of previous ablation procedures and the presence of ischemic cardiomyopathy (ICM). Follow-up duration is expressed in days, reflecting the observation period for each study. \dominitoc Krause et al. (2023) CR Germany 1 33 1 (100%) 1 (100%) 1 (100%) NA 90 Steyer et al. (2024) CR Germany 1 75 1 (100%) 1 (100%) 1 (100%) NA 17 Weyand et al. (2023) CR Germany 1 61 1 (100%) 1 (100%) 0 (0%) NA NA Ollitrault et al. (2025) CR France 1 53 0 0 0 (0%) 1 (100%) 240 Yokoyama et al. (2025) CR France 1 33 1 (100%) 1 (100%) 1 (100%) NA 90 Ouss et al. (2022) CR Netherlands 1 69 1 (100%) 1 (100%) 1 (100%) NA 180 Mannion et al. (2025) CR Ireland 1 60 1 (100%) 1 (100%) 0 (0%) 1 (100%) 90 Adragao et al. (2023) CR Portugal 1 60 1 (100%) 1 (100%) 1 (100%) 1 (100%) 2 Aguilera et al. (2024) CR USA 1 74 1 (100%) 1 (100%) 1 (100%) 1 (100%) 120 Martin et al. (2023) CR UK 1 68 1 (100%) 1 (100%) 1 (100%) 1 (100%) 60 Katrapati et al. (2024) CR USA 1 70 0 1 (100%) 1 (100%) 1 (100%) 72 Cespón-Fernández et al. (2024) CR Belgium 1 60 1 (100%) 1 (100%) 1 (100%) 0 180 Fassini et al. (2024) CS Italy 2 68 ± 6 2 (100%) NA 2(100%) 2(100%) 180 Prajapati et al. (2025) CS USA 2 69 ± 10 2 (100%) 2(100%) 0 (0%) 2(100%) 90 Younis et al. (2025)* CS USA 9 70 ± 7 9 (100%) 9(82%)† 7(78%) 7(78%) 212 ± 56 Lozano-Granero et al. (2023) CS Spain 3 78 ± 8 2 (66.7%) NA 1(33%) NA 150 ± 30 Pannone et al. (2024) RL Belgium 4 56 ± 19 4 (100%) 3 (75%) 3(75%) 1(25%) 150 ‡ Peichl et al. (2024)* PC Czechia 23 63 ± 15 18 (78.3%) NA 17 (74%) NA 116 ± 75 Ruwald et al. (2025)* PC Denmark 11 59 ± 13 8 (72.7%) 9(82%) 4(36%) 6 (55%) 230 ± 132 Padisak et al. (2025) CS Hungary 5 51 ± 14 3 (60%) 5 (100%) 5 (100%) 2 (40%) 106 ± 58 Footnotes : Data are presented as number (%) for categorical variables and as mean ± SD or median (minimum–maximum) for continuous variables, unless otherwise specified. CR = case report; CS = case series; ICD = implantable cardioverter defibrillator; ICM = ischemic cardiomyopathy; NA = not available; PC = prospective cohort; RL = research letter; SD = standard deviation; Hx = history *Only patients with VT are considered. †includes PVC patients. ‡ Median Table 2 Title: Bayesian estimates of procedural success by analysis level and group. Description: Results from unadjusted subgroup models, univariable meta-regressions, and the full multivariable meta-regression are presented. Posterior probability estimates and absolute probability differences (Δ) are shown with 95 percent CrIs. Δ indicates the change in success probability corresponding to the log-odds difference; values labeled “inconclusive” have CrIs that include both clinically meaningful benefit (>+10 percent) and detriment (<–10 percent). Unadjusted Subgroup Case-Based studies 93.8% (85.7% to 97.6%) — PFA + RFA 88.0% (77.0% to 94.5%) — Observational studies 75.1% (50.5% to 88.2%) — PFA-only 87% (74.2% to 94.3%). — Univariable: Study Design Observational vs. Case-Based 84.7% (69.4% to 95.1%) vs. 92.1% (83.7% to 97.2%) –7.4pp (–27.8pp to 11.4pp), inconclusive Univariable: Ablation Strategy PFA + RFA vs. PFA only 89.6%% (79.1% to 96.5%) vs 89.3% (77.0% to 96.9%) +0.2 pp (–13.1 to 11.7 pp), Inconclusive Full Multivariable Observational vs. Case-Based 86.4% (58.6% to 98.3%) vs. 91.8% (80.2% to 97.9%) -5.3 pp (–31.0 to 8.5pp), inconclusive PFA + RFA vs. PFA only 93.0 (81.6% to 98.5%) vs 91.8% (80.2% to 97.9%) +1.2 pp ( –9.4 to 12.2 pp), inconclusive Sample Size (per SD increase) 93.1% (81.3% to 99.3%) –1.6 pp (-9.4 to 3.3 pp), inconclusive Table 3 Title: Bayesian estimates of VT recurrence by analysis level and group. Description: This table summarizes unadjusted subgroup recurrence risks, univariable meta-regression comparisons, and fully adjusted multivariable meta-regression results. Δ indicates the absolute difference in recurrence probability corresponding to the log-odds difference. Values labeled “excludes zero” are credible, while those spanning thresholds of clinical relevance are inconclusive. \dominitoc Unadjusted Subgroup Case-Based 16.4% (8.5 to 28.4%) — Observational studies 50.6% (31.6 to 69.0%) — PFA+RFA 27.5% (14.0 to 44.4%) — PFA 27.5% (13.7 to 45.2%) — Univariable: Study Design Observational vs. Case-Based 44.2% ( 21.1% to 64.5%) vs. 19.9% (9.6% – 33.2%) +24.3 pp (1.38 to 46.0 pp), excludes zero Univariable: Ablation Strategy PFA + RFA vs. PFA only 25.7% (9.6% to 44.6%)vs 24.8% (8.8% to 44.2%) 0.68 pp(–22.4 to +21.8 pp), Inconclusive Full Multivariable Observational vs. Case-Based 35.4% (7.8% to 71.2%) vs. 20.6% (7.5% to 39.3%) 14.9 pp (–13.0 to +49.6 pp), inconclusive PFA + RFA vs. PFA only 17.5% (6% to 35.2%) vs. 20.6% (7.5% to 39.3%) –3.1 pp (–22.1 to +16.1 pp), inconclusive Sample Size (per SD increase) 20.9% (7.56% to 39.8%) +4.1 pp (–5.0 to +16.3 pp), inconclusive Table 4 Title : Summary of procedural and post-procedural characteristics of included studies. Description: The table outlines key technical and clinical details for each included study, including the type of ablation performed (e.g., PFA or PFA+RFA), procedural approach, and application technique. Device-related parameters are summarized, such as the PFA catheter used, the mapping system employed, the mapping catheter type, and the mapping methodology. Procedural complications observed during the intervention and post-procedural complications occurring after the procedure are also reported. [1]¿p#1 Krause et al. PFA Endocardial NA FARAWAVE NA NA PM / SM / AM 0 (0%) 0 (0%) Steyer et al. PFA + RFA Endo-epicardial NA SPHERE 9 AFFERA SPHERE‑9 AM 1 (100%) 1 (100%) Weyand et al. PFA + RFA Endocardial NA TCSM‑C CARTO 3 PENTARAY SM / AM NA 0 (0%) Ollitrault et al. PFA Endocardial FLOWER AND BASKET FARAWAVE NA NA NA NA 0 (0%) Yokoyama et al. PFA Epicardial NA SPHERE 9 AFFERA SPHERE‑9 SM / AM 1 (100%) 0 (0%) Ouss et al. PFA Endocardial NA FARAWAVE NA NA SM / AM 0 (0%) 0 (0%) Mannion et al. PFA + RFA Endocardial NA SPHERE 9 AFFERA SPHERE‑9 SM 0 (0%) 0 (0%) Adragão et al. PFA + RFA Endocardial FLOWERLIKE FARAWAVE CARTO 3 OCTARAY SM / AM 1 (100%) 0 (0%) Aguilera et al. PFA + RFA Endocardial NA SPHERE 9 AFFERA SPHERE‑9 PM / SM / AM 0 (0%) 0 (0%) Martin et al. PFA Endocardial FLOWER AND BASKET FARAWAVE RHYTHMIA ORION SM / AM 0 (0%) 0 (0%) Katrapati et al. PFA Endocardial FLOWER FARAWAVE ENSITE HD GRID SM / AM 0 (0%) 0 (0%) Cespón‑Fernández et al. PFA + RFA Endo-epicardial NA TCSM‑C NA NA PM / SM / AM 1 (100%) 0 (0%) Fassini et al. PFA 1 (50%) PFA + RFA 1 (50%) Endocardial FLOWER FARAWAVE ENSITE HD GRID SM / AM 0 (0%) 0 (0%) Prajapati et al. PFA + RFA 2 (100%) Endocardial NA FARAWAVE ENSITE OPTRELL PM / SM 2 (100%) 0 (0%) Younis et al. PFA 1 (11%) PFA + RFA 8 (89%) Epicardial 1 (11%), Endocardial 8 (89%) FLOWER AND BASKET FARAWAVE CARTO 3 & ENSITE OPTRELL, OCTARAY, HD GRID PM / SM / AM 0 (0%) 0 (0%) Lozano‑Granero et al. PFA 2 (67%) PFA + RFA 1 (33%) Endocardial 2 (66%) Endo-epicardial 1 (33%) BASKET FARAWAVE CARTO 3 PENTARAY PM / SM / AM 0 (0%) 0 (0%) Pannone et al. PFA 1 (25%) PFA + RFA 3 (75%) Endocardial NA SPHERE 9 AFFERA SPHERE‑9 PM / SM / AM 0 (0%) 0 (0%) Peichl et al. PFA and PFA + RFA Endocardial NA TCSM‑C CARTO 3 NA PM / SM / AM 3 (13%) 0 (0%) Ruwald et al. PFA 11 (100%) Endocardial NA NA CARTO 3 OCTARAY PM / SM / AM 3(27%) 0(0%) Padisak et al. PFA 5 (100%) Endocardial FLOWER FARAWAVE CARTO 3 PENTARAY PM / SM / AM 0 (0%) 0 (0%) Footnotes: AM = activation mapping; NA = not available; PFA = pulse field ablation; PM = pace mapping; RFA = radiofrequency ablation; SM = substrate mapping; TSCM-C = ThermoCool SmartTouch with Centauri System. Figure Legends Figure 1 Title : Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram illustrating the process of study selection. Description: A total of 254 records were initially identified through database searching. Of these, 20 studies were included in the final meta-analysis, 6 of which had also been reported in a previously conducted systematic review, and 14 were newly identified. Figure 2 Title : Forest Plot of Posterior Log-Odds for Acute Success Stratified by Study Design. Description: This forest plot displays the posterior mean log-odds and corresponding 95% credible intervals (CrIs) for acute success, estimated from a Bayesian hierarchical model. Each dot (●) represents the estimate for an individual study, while each diamond(◆) represents the subtotal estimate for a study design subgroup (Observational or Case-Based). The horizontal lines indicate 95% CrIs derived from the posterior distribution, reflecting the uncertainty around each estimate. Estimates are presented on the log-odds scale to maintain consistency with the modeling approach. Positive values correspond to higher odds of acute success, while negative values indicate lower odds. Subgroup estimates (diamonds) are based on the posterior of the model intercept for each group. Figure 3 Title : Forest Plot of Posterior Log-Odds for Acute Success Stratified by Ablation Type. Description: This forest plot presents the posterior mean log-odds and associated 95% credible intervals (CrIs) for arrhythmia recurrence, derived from a Bayesian hierarchical model. Each ● black dot represents the estimate for an individual study, while each ◆ blue diamond corresponds to the pooled (subtotal) estimate for the respective ablation group: PFA-only and Hybrid (combined PFA + RFA). The horizontal lines represent 95% CrIs, indicating uncertainty in each posterior estimate. Estimates are plotted on the log odds scale, where values less than zero suggest a lower probability of recurrence, and values greater than zero suggest a higher probability. Subgroup-level estimates provide pooled summaries based on the posterior distribution of group-level intercepts Figure 4 Title : Forest Plot of Posterior Log-Odds for Arrhythmia Recurrence by study design. Description: This forest plot displays the posterior mean log-odds and corresponding 95% credible intervals (CrIs) for arrythmia recurrence, estimated from a Bayesian hierarchical model. Each dot (●) represents the estimate for an individual study, while each diamond(◆) represents the subtotal estimate for a study design subgroup (Observational or Case-Based). The horizontal lines indicate 95% CrIs derived from the posterior distribution, reflecting the uncertainty around each estimate. Estimates are presented on the log-odds scale to maintain consistency with the modeling approach. Positive values correspond to higher odds of acute success, while negative values indicate lower odds. Subgroup estimates (diamonds) are based on the posterior of the model intercept for each group. Figure 5 Title: Forest Plot of Posterior Log-Odds for Arrythmia Recurrence Stratified by Ablation Type. Description : This forest plot presents the posterior mean log-odds and associated 95% credible intervals (CrIs) for arrhythmia recurrence, derived from a Bayesian hierarchical model. Each ● black dot represents the estimate for an individual study, while each ◆ blue diamond corresponds to the pooled (subtotal) estimate for the respective ablation group: PFA-only and Hybrid (combined PFA + RFA). The horizontal lines represent 95% CrIs, indicating uncertainty in each posterior estimate. Estimates are plotted on the log-odds scale, where values less than zero suggest a lower probability of recurrence, and values greater than zero suggest a higher probability. Subgroup-level estimates provide pooled summaries based on the posterior distribution of group-level intercepts. Information & Authors Information Version history V1 Version 1 19 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical: catheter ablation – non-rf energy sources clinical: catheter ablation – ventricular tachycardia clinical: electrophysiology – ventricular tachycardia Authors Affiliations Faizan Abbas 0009-0005-5176-1680 [email protected] Fatima Memorial Hospital View all articles by this author Aniq Saleem Fatima Memorial Hospital View all articles by this author Johar Raza Allama Iqbal Medical College View all articles by this author Muhammad Hamza Rana Conemaugh Memorial Medical Center View all articles by this author Hazem Abozguia Marshall University View all articles by this author Khalid Abozguia Marshall University Joan C Edwards School of Medicine View all articles by this author Metrics & Citations Metrics Article Usage 472 views 165 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Faizan Abbas, Aniq Saleem, Johar Raza, et al. Pulsed Field Ablation for Ventricular Tachycardia: A Systematic Review and Exploratory Bayesian Meta-Analysis of Non-Randomized Studies. Authorea . 19 September 2025. DOI: https://doi.org/10.22541/au.175828522.23936840/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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