Join Digital Education Committee member and podcast host Melissa E. Middeldorp, MPH, PhD, along with this week's guest contributors, Joshua Silverstein MD, FHRS from Allegheny Health Network and Jonathan Ariyaratnam, BChir, MA, MB, CCDS, CEPS-A from the University of Adelaidefor this week's episode.

Article for Discussion

Learning Objectives

• Understand how imaging- and ECG-based markers of atrial cardiomyopathy are defined and how they relate to the risk of incident AF, heart failure, and stroke.
• Evaluate how integrating atrial cardiomyopathy markers with clinical and genetic risk scores may improve risk stratification for AF and related cardiovascular outcomes.

Article Authors

Oliver B Vad, Nick van Vreeswijk, Ahmed S Yassin, Yuri Blaauw, Christian Paludan-Müller, Jørgen K Kanters, Claus Graff, Ulrich Schotten, Emelia J Benjamin, Jesper H Svendsen, Michiel Rienstra

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD
Joshua R. Silverstein, MD, FHRS
Jonathan Ariyaratnam, BChir, MA, MB, CCDS, CEPS-A

Host and Contributor Disclosure(s):

M. Middeldorp

• Honoraria/Speaking/Consulting: Medical Device Business Services, Biosense Webster, Inc., Medtronic
• Stocks, Privately Held: Heart Rhythm Clinical Solutions/3PH Alliance

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee member and podcast host Melissa E. Middeldorp, MPH, PhD, along with this week's guest contributors, Nino Isakadze, MD, MHS, and Geraldine A. Lee, PhD, FESC for this week's episode.

The POP-AF trial was a prospective, randomized controlled study evaluating whether a nurse-led, integrated lifestyle intervention before AF ablation improves outcomes. A total of 145 patients with symptomatic paroxysmal or persistent AF and at least one modifiable risk factor were randomized to either standard pre-ablation care or a structured, multidisciplinary lifestyle program targeting weight loss, physical activity, alcohol reduction, smoking cessation, blood pressure, lipid and glycemic control, and obstructive sleep apnea treatment. After pulsed-field pulmonary vein isolation, patients were followed for 12 months. The primary endpoint, a composite of repeat ablations and cardioversions was reduced by 51% in the intervention group (IRR 0.49, 95% CI 0.30–0.78). Successful index ablation without antiarrhythmic drugs was also significantly higher (76% vs 53%). Notably, these benefits were achieved with an average weight loss (~5.5%), suggesting that comprehensive, personalized risk-factor management meaningfully enhances rhythm control outcomes when implemented before ablation.

Read the Article

Learning Objectives

• Understand how a structured, nurse-led integrated lifestyle intervention before AF ablation significantly reduces repeat procedures and cardioversions compared with standard care.
• Evaluate the role of comprehensive risk-factor modification which includes weight, blood pressure, alcohol use, and OSA management improves rhythm control outcomes in patients undergoing PVI.

Article Authors

Jasper Vermeer, Tineke Vinck-de Greef, Maarten van den Broek, Bianca de Louw, Gijs van Steenbergen, Dennis van Veghel, Lukas Dekker

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD
Nino Isakadze, MD, MHS
Geraldine A. Lee, PhD, FESC

All relevant financial relationships have been mitigated.

Host and Contributor Disclosure(s):

M. Middeldorp

• Research: Apple, Inc., Itamar Medical
• Board Membership: Boston Scientific

• Research: H2020 (EHRA-PATHS)

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee member and podcast host Deep Chandh Raja, MBBS, MD, PhD, along with this week's guest contributors, Senthil Thambidorai, MD, FHRS and Lee Karl Thien, MD, CCDS for this week's episode.

This real-world registry study evaluated the safety, feasibility, and mid-term outcomes of pulsed field ablation (PFA) for cavotricuspid isthmus (CTI)–dependent atrial flutter. Acute bidirectional CTI block was achieved in nearly all patients, with a low complication rate and high freedom from recurrent flutter at mid-term follow-up. The findings suggest that PFA is an effective non-thermal alternative for typical atrial flutter ablation, though long-term durability and comparisons with conventional thermal energy sources require further investigation.

Learning Objectives

• Describe the procedural success rates and safety profile of pulsed field ablation for CTI-dependent atrial flutter.
• Compare pulsed field ablation with traditional thermal ablation strategies for typical atrial flutter.
• Discuss the role of emerging ablation technologies in the management of supraventricular tachyarrhythmias.

Article Authors
Juan F. Rodriguez-Riascos, MD, Hema S. Vemulapalli, MBBS, Poojan Prajapati, MBBS, Padmapriya Muthu, MBBS, James Y. Kim, MD, Dan Sorajja, MD, Win-Kuang Shen, MD, Hicham El Masry, MD, Mayank Sardana, MBBS, MD, Arturo M. Valverde, MD, Thomas M. Munger, MD, and Komandoor Srivathsan, MD

Podcast Contributors
Senthil Thambidorai, MD, FHRS
Lee Karl Thien, MD, CCDS
Deep Chandh Raja, MBBS, MD, PhD

All relevant financial relationships have been mitigated.

Host and Contributor Disclosure(s):

D. Raja
Nothing to disclose.

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Vice-Chair and podcast host Tina Baykaner, MD, MPH, along with this week's guest contributors, Jackson J. Liang, DO and Edward P. Gerstenfeld, MD, MS, FHRS for this week's episode.

This study evaluates the relationship between hospital ventricular tachycardia (VT) ablation volume and post-procedural complications, examining whether institutional procedural experience influences patient outcomes. The authors analyze complication rates across centers with varying VT ablation volumes to assess potential volume–outcome associations. Findings from this work provide important insights into procedural risk, quality metrics, and the potential impact of case volume on VT ablation safety.

Learning Objectives

• Describe the relationship between hospital VT ablation procedural volume and post-procedural complication rates.
• Identify patient, procedural, and institutional factors that may contribute to complications following ventricular tachycardia ablation.
• Discuss how volume–outcome findings can inform quality improvement initiatives, referral patterns, and procedural planning for VT ablation programs.

Article Authors

Agam Bansal, Anirudh Nandan, Jakub Sroubek, Justin Lee, Koji Higuchi, Ayman Hussein, Shady Nakhla, Mina Chung, Niraj Varma, Walid Saliba, Mandeep Bhargava, Tyler Taigen, Mohamed Kanj, Oussama Wazni, and Pasquale Santangeli

Podcast Contributors

Tina Baykaner, MD, MPH
Jackson J. Liang, DO
Edward P. Gerstenfeld, MD, MS, FHRS

All relevant financial relationships have been mitigated.

Host and Contributor Disclosure(s):

T. Baykaner
•Honoraria/Speaking/Consulting: Volta Medical, Medtronic, Pacemate, Johnson and Johnson, Abbot Medical, Boston Scientific
•Research: NIH

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Member and podcast host Jason T. Jacobson, MD, FHRS, along with this week's guest contributors, Gaurav A. Upadhyay, MD, FHRS and Pugazhendhi Vijayaraman, MD, FHRS for this exciting conversation!

This Heart Rhythm Journal article explores the electrophysiologic signatures that occur during left bundle branch pacing (LBBP) as lead position changes, with a focus on identifying "uninterrupted transition" patterns in recorded electrograms. The findings help clarify how subtle lead movement within the interventricular septum can alter electrogram morphology and capture behavior, improving clinicians' ability to confirm true conduction system engagement during implantation.

Read the article

Learning Objectives

• Describe the electrophysiologic basis of lead position–dependent electrogram changes observed during left bundle branch pacing.
• Differentiate uninterrupted transition electrogram patterns from other pacing capture transitions (e.g., septal capture vs LBB capture).
• Apply electrogram transition findings to improve procedural decision-making for confirming optimal lead placement during LBBP implantation.

Article Authors
Jiabo Shen, MD, Longfu Jiang, MD, Hao Wu, MD, Lu Zhang, MD, Hengdong Li, MD, Lifang Pan, MD

Podcast Contributors
Gaurav A. Upadhyay, MD, FHRS
Pugazhendhi Vijayaraman, MD, FHRS
Jason T. Jacobson, MD, FHRS

Host and Contributor Disclosure(s):

J. Jacobson

• Honoraria/Speaking/Teaching/Consulting: Zoll Medical Corporation, Vektor Medical Inc.
• Stocks, Privately Held: Atlas 5D
• Research: CardioFocus, Inc.
• Membership on Advisory Committees: Abbott Medical, Johnson and Johnson

G. Upadhyay

• Honoraria/Speaking/Teaching/Consulting: Boston Scientific, Abbott, Medtronic, Biontronik, Zoll Medical Corporation

• Honoraria/Speaking/Consulting: Medtronic, Boston Scientific, Biotronik, Abbott Medical, Abbott
• Research: Medtronic
• Fellowship Support: Medtronic

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Welcome to this week's episode of The Lead. Join HRS Digital Education Committee member and podcast host Danesh Kella, MBBS, FHRS as he welcomes his guests Rahul N Doshi, MD, FHRS and Robert D Schaller, DO, FHRS. They are discussing Mechanical Vacuum Aspiration and Debulking of Large Vegetations During Cardiac Implantable Electronic Device Extractions, which was published in the Journal of the American College of Cardiology in October 2025.

This article describes the use of mechanical vacuum aspiration systems to debulk large intracardiac vegetations during cardiac implantable electronic device (CIED) extraction, aiming to reduce embolic risk and procedural complications. The authors highlight procedural techniques, patient selection, and safety considerations when combining aspiration with transvenous lead extraction. This approach represents an important adjunctive strategy for managing complex CIED infections with large vegetations.

Learning Objectives

• Describe the role of mechanical vacuum aspiration in the management of large vegetations during CIED extraction procedures.
• Identify patient selection criteria and procedural considerations for safely combining vegetation debulking with transvenous lead extraction.
• Recognize potential risks, benefits, and complications associated with aspiration-assisted extraction in patients with CIED infection.

Article for Discussion: https://www.jacc.org/doi/10.1016/j.jacc.2025.07.043

Article Authors

Yury Malyshev, Marc A. Miller, Anelechi Anyanwu, George C. Shaw, Mouhannad Sadek, Seth Newman, Sakshum Chadha, Maryam Saleem, Nana Gegechkori, Abhishek Maan, Daniel Musikantow, Mohit Turagam, William Whang, Joshua Lampert, Jacob Koruth, Srinivas Dukkipati, Eric Neibart, and Vivek Y. Reddy

Podcast Contributors

Danesh Kella, MBBS, FHRS
Rahul N Doshi, MD, FHRS
Robert D Schaller, DO, FHRS

Host and Contributor Disclosure(s):

D. Kella

• Honoraria/Speaking/Teaching/Consulting: Zoll Medical Corporation, MBW Spectrum

• Honoraria/Speaking/Teaching/Consulting: Boston Scientific, Kestra, Inc., Abbott, Impulse Dynamics

• Honoraria/Speaking/Consulting: Medtronic, Boston Scientific, Philips, Cook Medical
• Research: Abbott Medical

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Member and podcast host Deep Chandh Raja, MBBS, MD, PhD , and his guests Georgios Leventopoulos, MD, and Muthiah Subramanian, MD, CCDS, CEPS-A, for this week's Lead episode.

This Heart Rhythm article investigates the Bachmann bundle as a target for pacing by using retrograde electrical mapping and correlating findings with underlying myocardial microstructure. The piece provides detailed insights into how Bachmann bundle activation pathways relate to tissue architecture, with implications for optimizing physiologic pacing strategies. These findings may help refine pacing techniques that aim to better mimic natural conduction and improve clinical responses.

Learning Objectives

• Describe the anatomical and electrophysiologic characteristics of the Bachmann bundle and its role in atrial conduction.
• Explain how retrograde mapping and microstructural correlation can identify optimal pacing targets within the atrial conduction system.
• Evaluate the potential clinical implications of Bachmann bundle pacing for achieving more physiologic atrial activation.

Article Authors

Daniel L. Lustgarten, MD, PhD, FHRS, Nicole Habel, MD, PhD, Margaret Infeld, MD, MS, Daniel Correa de Sa, MD, Robert Lobel, MD, Peter Spector, MD, FHRS, Nathaniel Thompson, MD, Joseph Winget, MD, Neal Duong, BME, Bo Ye, MD, PhD, Paul A. Iaizzo, PhD, Markus Meyer, MD, PhD

Podcast Contributors

Deep Chandh Raja, MBBS, MD, PhD

Georgios Leventopoulos, MD

Muthiah Subramanian, MD, CCDS, CEPS-A

Article Being Discussed

Host and Contributor Disclosure(s):

G. Leventopolous

• Nothing to disclose.

D.C. Raja

• Nothing to disclose.

Join Digital Education Committee Chair and podcast host Michael S. Lloyd, MD, FHRS, and his guests Kelvin C. Chua, MBBS, MD, FHRS, CEPS-A, and Rahul N Doshi, MD, FHRS, for this week's Lead episode, which was recorded live at APHRS 2025 in Kyoto, Japan.

This discussion will review recent evidence on the feasibility and safety of pulsed field ablation (PFA) for coronary sinus and left atrial appendage isolation, as well as mitral isthmus ablation, focusing on both acute and chronic outcomes. Panelists will examine procedural considerations, lesion durability, and safety signals highlighted in the study, and explore how these findings may inform evolving ablation strategies for complex atrial arrhythmias.

Learning Objectives

• Summarize the acute and chronic feasibility and safety outcomes of pulsed field ablation (PFA) for coronary sinus isolation, left atrial appendage isolation, and mitral isthmus ablation as reported in the study.

• Evaluate procedural techniques and lesion durability considerations associated with using PFA in anatomically complex atrial structures.

• Assess the potential clinical implications of these findings for incorporating PFA into ablation strategies for complex atrial arrhythmias, including patient selection and risk mitigation.

Podcast Contributors

Michael S. Lloyd, MD, FHRS
Kelvin C. Chua, MBBS, MD, FHRS, CEPS-A
Rahul N Doshi, MD, FHRS

Host and Contributor Disclosure(s):

K.C. Chua
•Nothing to disclose.

R. N. Doshi
•Speaking/Teaching/Consulting/Authoring: Boston Scientific, Kestra Inc., Abbott, Impulse Dynamics USA