EP Edge Journal Watch

About EP Edge Journal Watch

Welcome to EP Edge Journal Watch, where cardiac electrophysiology meets evidence, precision, and perspective. Hosted by Dr. Niraj Sharma, this weekly podcast distills high-impact cardiovascular and Cardiac Electrophysiology and arrhythmia research into clear, clinically meaningful insights. Each episode goes beyond headlines and abstracts to uncover what new studies actually mean for patient care, decision-making, and the future of electrophysiology. What EP Edge Journal Watch stands for: Evidence-based practice Precision electrophysiology, arrhythmias analysis A forward-thinking, edge-driven approach to how we interpret and apply data in real-world clinical settings. Whether you’re an electrophysiologist, cardiologist, researcher, trainee, or allied health professional, EP Edge Journal Watch brings you the signal not the noise. Expect sharp summaries, thoughtful commentary, and practical takeaways designed for the busy clinician who wants to stay ahead of the curve

Publisher

Niraj Sharma MD FACC FHRS: Cardiac Electrophysiology & Cardiology

Category

health & fitness · science

Language

en

Explicit

No

First episode

30 Oct 2025

Latest episode

5 Oct 2026

Latest episodes

48 episodes in the feed.

1. 

   5 Oct 2026

   EP Edge® Journal Watch 39 | October 2026: PIFPAF-PFA, Ablation Durability and Left Bundle Area ICD Leads

   Should we add posterior wall isolation during pulsed field ablation for persistent atrial fibrillation? How durable are pulmonary vein isolation and additional atrial lines? Can a defibrillation lead placed in the left bundle branch area provide reliable early performance while simplifying device therapy? Join Dr. Sharma for EP Edge® Journal Watch Issue 39, October 2026. We examine four papers in depth: PIFPAF-PFA, pulmonary vein isolation durability across pulsed field systems, invasive remapping of atrial lesion sets with a dual-energy lattice-tip catheter, and the LEADR LBBAP defibrillation lead study. We then give brief takeaways from twenty additional articles spanning AF ablation safety, conduction system pacing and cardiac resynchronization therapy, anticoagulation, metabolic therapies, AF progression and burden, cardioversion, cardiac arrest, ventricular arrhythmias, congenital long QT syndrome, and lead extraction. Our aim is to connect clinically relevant findings with the methods and uncertainty behind them. We distinguish acute procedural success from chronic durability, electrical surrogates from patient outcomes, and randomized evidence from selected observational comparisons. We explain effect estimates, denominators, confidence intervals, and why a nonsignificant result does not establish equivalence. Accompanying editorials and the pacing viewpoint are integrated into the relevant discussions rather than counted as additional articles. The newsletter contains detailed analyses of all 24 articles. The episode concentrates its extended analysis on the four featured papers below; the other twenty receive concise spoken takeaways. Article numbers retain the revised newsletter numbering, and entries follow newsletter order within each coverage section. FOUR PAPERS COVERED IN DEPTH 1. Pulmonary Vein Isolation Using Pulsed Field Ablation With vs Without Posterior Wall Isolation in Patients With Symptomatic Persistent Atrial Fibrillation: The PIFPAF-PFA Randomized Clinical Trial Roten L, Maurhofer J, Krisai P, et al. | JAMA | August 2026 Roten and colleagues ask whether empirical posterior wall isolation adds benefit to PFA-based PVI at first ablation for symptomatic persistent AF. In 206 randomized patients with continuous implantable-monitor surveillance, one-year Kaplan-Meier atrial tachyarrhythmia recurrence estimates were 50.6% with posterior wall isolation versus 60.6% with PVI alone. The primary result did not establish superiority: rate ratio 0.75, 95% CI 0.51–1.09, P=.13. Mean arrhythmia burden was 6.9% versus 11.0%, and episodes lasting at least one day occurred in 10 versus 25 patients. These secondary signals require confirmation because multiple comparisons were not corrected, and most secondary endpoints were nonsignificant. Repeat intervention, drug use, and quality-of-life comparisons did not establish an advantage. We integrate Kistler and Chieng’s editorial on empirical anatomical ablation versus targeting demonstrated substrate, while avoiding cross-trial claims of superiority. Routine additional posterior wall isolation remains unproven in this setting; limited power also prevents a conclusion of equivalence. DOI: 10.1001/jama.2026.17598 (https://doi.org/10.1001/jama.2026.17598) 2. Durability of pulmonary vein isolation: Does the pulsed field ablation system matter? Kakarla S, Iwakawa H, Ariyaratnam JP, et al. | Heart Rhythm | October 2026 Kakarla and colleagues compare pentaspline and balloon-in-basket PFA in a retrospective two-center cohort of 132 index procedures. Clinical recurrence was 10.5% versus 19.6% (P=.12), and 34 propensity-matched clinical pairs had six versus seven recurrences. The notable durability signal came from only 17 selected patients returning for repeat ablation: reconnection affected 9/32 versus 1/35 veins, and all veins remained isolated in 3/8 versus 8/9 patients. We examine why these findings cannot establish platform superiority. Matching of the clinical cohort did not randomize or make the separate redo sample representative. Veins within patients are correlated, monitoring intensity differed, and posterior wall treatment was uneven. Acute isolation, selected invasive remapping, and clinical recurrence answer different questions. The study supports prospective comparison with systematic remapping and standardized surveillance, while emphasizing mapping of the actual recurrence mechanism at redo. DOI: 10.1016/j.hrthm.2026.05.018 (https://doi.org/10.1016/j.hrthm.2026.05.018) 5. Durability of atrial linear lesion sets using a dual-energy lattice-tip catheter: Data from invasive remapping Nies M, Benesch Vidal ML, My I, et al. | Heart Rhythm | October 2026 Nies and colleagues investigate whether acute atrial block persists after ablation with a dual-energy lattice-tip catheter. Only 39 of 252 treated patients underwent remapping, for recurrence or planned appendage occlusion. The 71 remapped lesion sets comprised 18 pulmonary vein encirclements and 53 additional lines. Durable block was present in 54/71 sets; separately, 31/36 individual veins remained isolated. Roof lines, posterior boxes, and cavotricuspid lines remained blocked in 6/6, 10/10, and 7/7 cases, respectively. Anterior and mitral lines were durable in only 9/17 and 7/13. Small denominators, different remapping intervals, mixed energy strategies, and selected patients preclude controlled comparisons of energy or lesion location. We discuss the clinical consequences of gaps and macroreentry, the need to confirm bidirectional block when a line is indicated, and why visual continuity or promising remapping proportions do not establish better clinical outcomes. DOI: 10.1016/j.hrthm.2026.05.004 (https://doi.org/10.1016/j.hrthm.2026.05.004) 9. Safety and performance of a novel defibrillation lead for left bundle branch area placement: Primary results of the LEADR LBBAP clinical trial Vijayaraman P, Liu X, Denman R, et al. | Heart Rhythm | October 2026 issue Vijayaraman and colleagues report early safety and performance of a novel ICD lead designed for left bundle branch area placement. This prospective single-arm study enrolled 323 patients; implantation succeeded in 293/307 attempts. All 162 patients completing protocol defibrillation testing met the acute efficacy endpoint, exceeding a historical performance benchmark. Mean follow-up was only 2.6 months. Pacing thresholds were low and stable, while five major lead-related complications required revision; estimated freedom from major lead-related complications was 97.9% at three months. We distinguish implantation, testing, pacing, sensing, and complication denominators. Successful protocol testing does not guarantee future spontaneous-arrhythmia termination or chronic lead integrity. Approximately half received an additional LV lead, and left bundle area placement did not uniformly confirm conduction system capture. The study therefore does not establish that this lead alone replaces conventional CRT. Manufacturer sponsorship, incomplete testing, and short follow-up reinforce the need for independent long-term data on defibrillation, capture, sensing, mechanical reliability, and extraction. The October 2026 issue follows the paper’s 2025 online publication. DOI: 10.1016/j.hrthm.2025.10.028 (https://doi.org/10.1016/j.hrthm.2025.10.028) TWENTY ADDITIONAL ARTICLES WITH BRIEF PODCAST TAKEAWAYS 3. Dosing of single-shot pulsed field ablation systems: A systematic review of efficacy and safety balance Bax IN, Bolhuis RE, van der Graaf M, ...

2. 

   28 Sept 2026

   EP Edge® Journal Watch Issue 38 September 2026 with Heart Rhythm Society at HRX: AI ECG Interpretation, Wearable-Detected Ventricular Tachycardia, and LBBAP vs Deep Septal Pacing

   In this special EP Edge® Journal Watch Issue 38, recorded at HRX, with the Heart Rhythm Society Live 2026 in Atlanta, Dr. Niraj Sharma is joined by Dr. Michael Lloyd, Professor of Medicine at Emory University, for a focused discussion of three provocative studies with direct implications for contemporary cardiac electrophysiology. First, they examine the emerging role of large language models and artificial intelligence in ECG interpretation. How accurately can off-the-shelf, zero-shot LLMs interpret electrocardiograms, and are currently available general-purpose AI models ready to participate in clinical ECG analysis? The discussion then turns to ventricular tachycardia detected during everyday life by wearable devices. New data suggest that VT may be detected far more frequently in individuals using wearable monitoring than traditional estimates would suggest. Drs. Sharma and Lloyd discuss what these findings may mean for electrophysiologists increasingly confronted with rhythm data generated outside the clinic. Finally, the episode explores the continuing evolution of conduction system pacing, with new data comparing left bundle branch area pacing (LBBAP) and deep septal pacing (DSP). The conversation examines differences in clinical outcomes, the reported mortality signal associated with deep septal pacing, and an important practical problem for the field: inconsistent agreement about what actually constitutes successful LBBAP versus deep septal pacing. Recorded from HRX Live 2026, this episode goes beyond the abstracts to examine what the findings mean clinically, where the uncertainties remain, and how they may influence electrophysiology practice. Topics discussed include: Artificial intelligence and zero-shot LLMs for ECG interpretation Accuracy and limitations of AI-assisted electrocardiogram analysis Wearable cardiac monitoring and real-world ventricular tachycardia detection Ventricular arrhythmias detected outside traditional clinical monitoring Left bundle branch area pacing (LBBAP) Deep septal pacing (DSP) Conduction system pacing definitions and adjudication Mortality and clinical outcomes with physiologic pacing strategies Emerging research and innovation from HRX Live 2026 EP Edge® Journal Watch provides clinically focused analysis of important new research in cardiac electrophysiology, emphasizing not simply what a study found, but how the evidence should be interpreted and what it may mean for clinical practice. Hosted by Dr. Niraj Sharma Special HRX discussion with Dr. Michael Lloyd, MD, FACC, FHRS

3. 

   21 Sept 2026

   EP Edge® Journal Watch 37: LAAO vs DOACs, PFA Stroke Risk, Wearable AF Monitoring, PVC Localization, and SGLT2 Sudden Death

   In EP Edge® Journal Watch Issue 37, September 2026, Dr. Sharma reviews 13 important studies in cardiac electrophysiology, with a focus on what the data actually mean for clinical practice. This episode goes beyond abstracts and headline results to examine why each study was performed, the clinical question investigators were trying to answer, the methodology used, the statistics behind the major findings, important limitations, and what the results may mean for electrophysiologists going forward. This episode begins with a major theme in contemporary atrial fibrillation care: left atrial appendage occlusion and stroke prevention. First, we examine the mechanistic study “Left Atrial Appendage Thrombosis in Patients With Atrial Fibrillation” from Ji Zhou and colleagues. Histologic examination of surgically removed appendages from LAAOS III participants identified microscopic thrombi in the trabecular crypts, raising important questions about persistent local thrombogenicity despite anticoagulation and providing biological context for why mechanical left atrial appendage exclusion may provide additional protection in selected patients. We then turn to two important meta-analyses comparing left atrial appendage occlusion with medical therapy. The contemporary randomized evidence suggests that LAAO may substantially reduce nonprocedural bleeding, but the possibility of a modest increase in ischemic stroke remains unresolved. The discussion focuses on why LAAO should be viewed as a trade-off between procedural risk, long-term bleeding exposure, and stroke protection rather than simply as an equivalent replacement for direct oral anticoagulation. The episode then examines the ADVANCE LAA study, led by Dhanunjaya Lakkireddy, evaluating Amulet implantation in patients who failed Watchman anatomical screening. Despite more challenging left atrial appendage anatomy, Amulet implantation remained highly successful, reinforcing an important practical concept: failure of one device geometry does not necessarily mean failure of the LAAO strategy. Next, we review randomized evidence comparing direct oral anticoagulants versus dual antiplatelet therapy after left atrial appendage closure. The pooled data showed markedly lower device-related thrombus with DOAC-based therapy and, perhaps surprisingly, less major and minor bleeding than with DAPT. The clinical question is no longer simply whether anticoagulation can be stopped, but what antithrombotic strategy provides the safest bridge through the early device-healing period. The second major theme is pulsed field ablation safety and lesion durability. A major Circulation study led by Enrico Ferro compared neurological outcomes after pulsed field ablation and radiofrequency ablation. Although absolute stroke and TIA rates remained low, PFA was associated with a higher 30-day neurovascular event rate in this observational registry. Dr. Sharma discusses the difference between relative and absolute risk, why propensity adjustment cannot eliminate residual confounding, and why rapid adoption of PFA makes rigorous post-market safety surveillance essential. We then examine “Transmurality and Autonomic Effects of Pulsed Field Ablation on the Mitral Isthmus” by Apoor Patel and colleagues. Using direct vein of Marshall recordings, investigators demonstrated that apparent endocardial mitral isthmus block frequently concealed persistent epicardial conduction. PFA alone achieved complete block in fewer than half of patients, while vein of Marshall ethanol infusion substantially increased block rates. The study also demonstrated that PFA generally spared local parasympathetic innervation, whereas ethanol infusion produced denervation. The findings raise important questions about how we define lesion completeness in the PFA era. The episode then moves to atrial fibrillation detection and prediction. The PAVA score, developed by Baptiste Maille and colleagues, attempts to identify patients at lower likelihood of AF detection after cryptogenic stroke using premature atrial contractions, age, significant valvular disease, and left atrial enlargement. The score performed well in internal validation but less strongly in external validation, highlighting why prediction models should be judged by more than their best AUC. We also discuss the study “Wearable smartwatches for atrial fibrillation detection and burden estimation after ablation: comparison with continuous monitoring.” Using continuous implantable cardiac monitor data from CIRCA-DOSE, investigators simulated Apple Watch and Fitbit AF-detection algorithms. Smartwatch strategies detected substantially more recurrence than conventional short Holter monitoring, while wearable-estimated AF burden correlated closely with continuous monitoring. The episode examines the critical distinction between correlation and agreement, and why simulation is not the same as prospective real-world validation. Another study evaluates the neutrophil-to-lymphocyte ratio as a predictor of postoperative atrial fibrillation after cardiac surgery. Elevated NLR was associated with postoperative AF, supporting an inflammatory component to arrhythmogenesis, but its standalone diagnostic performance was only moderate. This provides a useful example of why a statistically significant biomarker association does not automatically translate into a clinically useful prediction test. Two practical ventricular arrhythmia studies then return the discussion to the 12-lead ECG. Masafumi Sugawara and colleagues demonstrate that comparing the PVC QRS axis with the patient’s baseline sinus-rhythm axis may help distinguish true para-Hisian PVCs from RVOT and LVOT mimics. Rather than interpreting the ectopic beat in isolation, the study suggests that the patient’s baseline electrical orientation should become part of PVC localization. Yoshihisa Naruse and colleagues introduce the V6R/V4R index, a simple ECG parameter designed to distinguish aortic cusp ventricular arrhythmias from non-cusp LVOT origins. The index may help determine where mapping should begin, although the paper contains inconsistencies in the reported diagnostic performance that deserve careful interpretation. Finally, the episode explores whether SGLT2 inhibitors may reduce sudden cardiac death. Andrea Matteucci and colleagues pooled adjudicated randomized evidence involving empagliflozin and dapagliflozin across nearly 59,000 participants. SGLT2 inhibition was associated with approximately an 18 percent reduction in the odds of sudden cardiac death, with consistent results across the included trials. The key unanswered question is mechanism. Does this reflect a direct antiarrhythmic effect, or is sudden death reduced indirectly through improvements in heart failure, myocardial energetics, fibrosis, renal function, and overall cardiovascular stability? Throughout the episode, Dr. Sharma focuses on the difference between statistical significance and clinical significance, association versus prediction, relative versus absolute risk, and the practical implications of these studies for electrophysiology practice. Topics include: atrial fibrillation, left atrial appendage occlusion, Watchman, Amulet, DOACs, DAPT, device-related thrombus, pulsed field ablation, PFA safety, stroke after AF ablation, mitral isthmus ablation, vein of Marshall ethanol infusion, wearable AF monitoring, Apple Watch, implantable loop recorders, cryptogenic stroke, PAVA score, postoperative atrial fibrillati...

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