Mapping and ablation of intramural premature ventricular complexes: state-of-the-art review

PURPOSE OF REVIEW: Despite significant technological progress over the last decade, the optimal strategy for mapping and ablating intramural premature ventricular complexes (PVCs) remains elusive, with suboptimal success rates. RECENT FINDINGS: Recent studies have highlighted the limitations of traditional activation mapping and pointed towards newer indices for accurately localizing the site of origin (SOO) of intramural PVCs. Emerging technologies - including bipolar ablation, intramyocardial needle ablation, and pulsed field ablation - have demonstrated early promise in improving lesion depth and transmurality, potentially overcoming the constraints of conventional radiofrequency ablation. SUMMARY: Intramural PVCs are challenging for the electrophysiologist. While definitive strategies remain to be validated in large-scale, randomized studies, a pragmatic and systematic mapping approach, coupled with judicious use of conventional and emerging technologies, allows the electrophysiologist to circumvent the current limitations and achieve optimal outcomes in this challenging subset of ventricular arrhythmias. This review provides a contemporary overview and outlines a stepwise approach for managing intramural PVCs.