Adjunctive Purkinje Denetworking During Ventricular Tachycardia Ablation in Patients With Prior Ventricular Fibrillation.

BACKGROUND

Recurrence after ventricular tachycardia (VT) ablation remains common in patients with monomorphic VT and spontaneous polymorphic ventricular tachycardia (PMVT) or ventricular fibrillation (VF), suggesting mechanisms beyond myocardial scar alone. The Purkinje system plays a central role in both triggering and sustaining malignant ventricular arrhythmias. Whether adjunctive Purkinje de-networking (PDN) improves outcomes in this high-risk population is unknown.

OBJECTIVES

This study sought to determine whether adjunctive PDN during VT ablation is associated with improved arrhythmia outcomes in patients with prior spontaneous PMVT/VF.

METHODS

Multicenter retrospective cohort study of patients undergoing monomorphic VT ablation (2023-2025) with prior spontaneous PMVT or VF. Patients underwent VT ablation with adjunctive PDN (n = 27) or VT ablation alone (n = 28). The primary endpoint was 12-month VT/VF-free survival. Secondary endpoints included ICD therapies, repeated ablation, and procedural safety.

RESULTS

At 12 months, VT/VF-free survival was higher with adjunctive PDN (80.8% vs 49.2%; absolute difference: 31.6%). Adjunctive PDN was associated with lower VT/VF recurrence (HR: 0.29; 95% CI: 0.11-0.72; P = 0.017). When limited to PMVT/VF events, recurrence rates were lower in both absolute (7.4% vs 39.3%) and relative (HR: 0.20; 95% CI: 0.07-0.59; P = 0.018) terms. Implantable cardioverter-defibrillator therapies declined significantly after ablation in both groups (P < 0.001). Iatrogenic left bundle branch block occurred more frequently with PDN (14.8% vs 3.6%; P = 0.19), although no patients required permanent pacing or device upgrade.

CONCLUSIONS

In this high risk cohort, adjunctive PDN during VT ablation was associated with a substantial reduction in recurrent ventricular arrhythmias, with a modest increase in risk of left bundle branch block. These findings support prospective evaluation of PDN in patients with prior VF.