Planned anatomy-guided dual-sided (“Sandwich”) ablation improves recurrence-free survival in idiopathic premature ventricular contractions: a propensity-matched cohort study

Purpose: Catheter ablation of idiopathic premature ventricular contractions (IPVCs) is often challenged by intramural or anatomically complex substrates, where targeting only the site of earliest activation may result in insufficient lesion transmurality and arrhythmia recurrence. We aimed to determine whether a planned, anatomy-guided dual-sided (“sandwich”) ablation strategy improves long-term clinical outcomes compared with conventional ablation. Methods: We conducted a retrospective cohort study of patients undergoing catheter ablation for IPVCs. After exclusions, 412 patients were eligible, and 1:1 propensity score matching based on left ventricular ejection fraction, QRS duration, PVC burden, and anatomical localization yielded 97 well-balanced pairs (n = 194). The planned sandwich ablation strategy consisted of conventional ablation at the earliest activation site followed by systematic radiofrequency applications from anatomically adjacent or opposing myocardial surfaces. The primary endpoint was recurrence-free survival, defined as absence of sustained ventricular arrhythmia or PVC burden > 1% during follow-up; major complications constituted secondary endpoints. Results: Among 194 propensity-matched patients (mean age 50.6 ± 11.3 years; 52.1% male), sandwich ablation was associated with significantly higher recurrence-free survival compared with conventional ablation (94.8% vs. 78.4%; p = 0.001). Subgroup analysis demonstrated a marked benefit of sandwich ablation in patients with earliest activation time > − 30 ms (92.5% vs. 60.5%; p < 0.001). On multivariate Cox regression analysis, sandwich ablation emerged as an independent predictor of reduced recurrence (adjusted hazard ratio 0.28; 95% CI 0.10–0.76; p = 0.013). Major complication rates were comparable between groups. Conclusions: Planned dual-sided ablation may improve recurrence-free survival in IPVCs.