EP Edge™ Journal Watch: AVANT GUARD Trial, PFA as First-Line Therapy for Persistent AF: Half the Story

Inaugural EP EdgeTM Journal Watch with Heart Rhythm Society: AVANT GUARD, LAA Closure, OCEAN, and the ALONE-AF Cognitive Substudy

The inaugural EP Edge Journal Watch and Heart Rhythm Society collaboration is here. In this first episode, Dr. Michael Lloyd from the Heart Rhythm Society Digital Education Committee joins Dr. Niraj Sharma, creator of EP Edge, to launch a new monthly format focused on the most clinically relevant literature in cardiac electrophysiology. This is not a routine article summary. It is a practical, physician-led discussion of the studies that matter in the EP lab, in clinic, and at the bedside. Electrophysiology literature is moving quickly. Important trials now appear across major journals, late-breaking sessions, society meetings, and digital platforms. Algorithms can identify highly cited papers. Search tools can rank articles. But clinical relevance still requires judgment. EP Edge Journal Watch was created to help close that gap. The goal is simple: identify the papers that deserve attention, place them in clinical context, and ask what they mean for real patients. In this inaugural episode, Dr. Lloyd and Dr. Sharma begin with AVANT GUARD, a major trial evaluating first-line pulsed field ablation in patients with persistent atrial fibrillation. The discussion goes beyond the headline. They examine patient selection, drug-naive persistent AF, procedural safety, the stroke signal, modified enrollment criteria, anticoagulation requirements, endpoint design, and the difference between symptom reduction and true AF burden reduction. The episode then turns to one of the most active areas in atrial fibrillation care: left atrial appendage closure. Dr. Lloyd and Dr. Sharma discuss CLOSURE AF and CHAMPION AF, two trials that asked similar questions but studied very different patient populations. The discussion focuses on stroke risk, bleeding risk, frailty, procedural complications, endpoint construction, and how these trials should influence shared decision-making. The key clinical question is direct: should left atrial appendage closure be offered broadly as an alternative to anticoagulation, or should it remain focused on patients with a clear problem taking long-term oral anticoagulation? The final section focuses on anticoagulation after apparently successful AF ablation. Dr. Lloyd and Dr. Sharma discuss OCEAN and ALONE-AF, with attention to stroke risk, bleeding risk, patient selection, rhythm monitoring, and the limits of intermittent surveillance. For selected low-risk patients without recurrent atrial arrhythmia, stopping anticoagulation may be reasonable. But the decision is not automatic. It depends on the patient, the risk profile, the quality of rhythm follow-up, and the shared decision-making conversation. The episode also highlights the ALONE-AF cognitive substudy, one of the most interesting parts of the discussion. This substudy moves the conversation beyond stroke and bleeding. It asks whether stopping oral anticoagulation after successful AF ablation affects cognitive function. The key point is nuanced. In selected patients without recurrent atrial arrhythmia, stopping anticoagulation did not appear to produce a cognitive penalty. But the more provocative signal may be rhythm itself. Patients who maintained sinus rhythm appeared to have better cognitive trajectories than those with recurrence. That raises an important clinical question for the field: after AF ablation, is the long-term cognitive story less about the anticoagulant and more about durable rhythm control? This first episode sets the tone for the EP Edge Journal Watch and HRS collaboration. The format is concise, practical, and clinically grounded. It is built for busy electrophysiologists, cardiologists, fellows, advanced practice providers, and clinicians who care for patients with atrial fibrillation. The purpose is not just to summarize trials. It is to interpret them. Which patients were studied? Which endpoints matter? Which findings should change a clinic conversation? Which results should make us pause before changing practice? That is the mission of EP Edge Journal Watch with HRS.

EP Edge™ Journal Watch Issue 23 May 2026: PFA Durability, Posterior Wall Ablation, Outflow Tract PVCs, and Fitness as Substrate Modification

In EP Edge™ Journal Watch Issue 23, May 2026, Dr. Sharma reviews the latest high-impact electrophysiology and cardiology literature with a new focused format: four deep-dive studies and a rapid-fire review of the remaining trials. This episode explores whether pulsed field ablation platform design affects pulmonary vein isolation durability, how balloon-in-basket PFA may change posterior wall ablation, and whether focal PFA is ready for outflow tract PVC ablation. The episode also includes an EP-Edge™ Off-track deep dive on midlife cardiorespiratory fitness and healthy aging, highlighting fitness as upstream cardiovascular substrate modification. Rapid-fire discussions cover residual tiny pulmonary vein potentials after PFA, dronedarone versus amiodarone after AF ablation, AI versus electrophysiologist rhythm adjudication, quantitative Brugada risk stratification, smartwatch detection of Type I Brugada pattern, AV nodal left inferior extension mapping, IV lidocaine safety in AF patients treated for ventricular arrhythmias, and HEPARIN-STEMI. Topics include atrial fibrillation ablation, pulsed field ablation, posterior wall isolation, pulmonary vein durability, PVC ablation, Brugada syndrome, wearable ECG, artificial intelligence in electrophysiology, ventricular arrhythmias, STEMI systems of care, and cardiorespiratory fitness. Full references, graphics, and detailed trial analysis are available in the EP-Edge™ Journal Watch LinkedIn newsletter and on Substack at epedge.substack.com.

EP Edge Journal Watch Issue 22: PFA Safety, Lesion Durability, LAAO, Subcutaneous-ICD Testing & AF Ablation Success

In this episode of EP Edge® Journal Watch, Dr. Sharma reviews Issue 22, May 2026, focused on the next phase of electrophysiology: pulsed field ablation safety, lesion durability, long-term AF recurrence, one-stop AF procedures, device simplification, PAC suppression, and the evolving definition of ablation success. This issue begins with the Ferro EHRA 2026 real-world comparison of pulsed field ablation versus radiofrequency ablation for atrial fibrillation, highlighting why PFA safety should be interpreted by endpoint, workflow, platform, and lesion strategy rather than as a single global claim. The episode then examines NAVIGATE-PF Phase 2, a systematic remapping study of a second-generation, mapping-integrated pentaspline PFA catheter, and what early lesion durability tells us about the future of anatomically accountable PFA. Dr. Sharma also discusses long-term recurrence after pentaspline PFA, including predictors of AF recurrence and what redo procedures reveal about pulmonary vein reconnection among patients with recurrent arrhythmia. Additional studies include concomitant PFA plus left atrial appendage occlusion, exploring whether a one-stop AF strategy may improve procedural efficiency and reduce peridevice leak; PRAETORIAN-DFT, evaluating whether routine defibrillation testing can be omitted after S-ICD implantation when implant position is favorable; and a CT-based risk score for predicting difficult leadless pacemaker implantation. The episode also covers a provocative phase 2 randomized trial of memantine for premature atrial contractions, introducing NMDA receptor antagonism as a potential nontraditional pathway for atrial ectopy suppression. Finally, this issue closes with a critical look at how we define success after AF ablation. Is the traditional 30-second atrial arrhythmia recurrence endpoint still enough in the PFA era, or should future trials prioritize AF burden, symptoms, repeat procedures, antiarrhythmic drug use, quality of life, healthcare utilization, and safety by domain? This episode is designed for electrophysiologists, cardiologists, EP fellows, APPs, device specialists, and clinicians who want concise, clinically grounded interpretation of the latest EP literature. Full references and graphics are available in EP Edge Journal Watch on LinkedIn and Substack: epedge.substack.com. Questions, concerns and suggestions: epedgecast@gmail.com

EP Edge™ Journal Watch Issue 21 May 2026: AI-Guided AF Ablation, PFA/CIED Safety, VT Ablation, Cannabis and Arrhythmia Risk, HCM, HFpEF, RBBB, and Anticoagulation After AF Ablation

In this May 2026 episode of EP Edge™ Journal Watch, we review nine high-impact electrophysiology studies shaping contemporary EP practice. This issue covers AI-guided redo AF ablation, dual-energy lattice-tip ventricular arrhythmia ablation, pulsed field ablation safety in patients with cardiac implantable electronic devices, neuromodulation for PVC suppression, cannabis-associated atrial arrhythmia risk, sudden death risk after HCM myectomy, atrial fibrillation as a ventricular arrhythmia risk marker in HFpEF, post-ablation anticoagulation strategies, and a practical ECG marker for pacemaker risk in right bundle branch block. 1. RESTART Trial: AI-guided redo AF ablation in patients with isolated pulmonary veins The RESTART trial examines one of the most difficult redo AF scenarios: recurrent symptomatic atrial fibrillation despite durable pulmonary vein isolation. The study evaluates whether AI-guided electrogram dispersion mapping can identify non-PV substrate and guide a more disciplined redo ablation strategy rather than relying on empirical lesion sets. 2. CLEAR-VT: Dual-energy lattice-tip ablation for ventricular arrhythmias CLEAR-VT reports early U.S. experience using a dual-energy lattice-tip catheter capable of radiofrequency and pulsed field ablation for complex ventricular arrhythmias. The study is important because it highlights both the promise of broader lesion delivery in scar-related VT and the need for a new safety framework around device interaction, ventricular dosing, and substrate-specific limitations. 3. PFA/CIED safety cluster: Device reset, generator damage, VF, and lead-mediated risk This section reviews a group of reports describing clinically relevant interactions between high-energy ablation systems and pacemakers, ICDs, CRT devices, leadless pacemakers, and ICD coils. The key issue is that PFA is tissue selective, but it is still an electrical therapy delivered in patients with conductive hardware, making pre- and post-procedure device interrogation, imaging awareness, and lesion planning essential. 4. TREAT-PVC: Transcutaneous vagus nerve stimulation for PVC suppression TREAT-PVC tests whether low-level tragus stimulation can reduce symptomatic idiopathic PVC burden compared with sham stimulation. The central lesson is not simply whether neuromodulation works, but how strongly placebo effects, PVC variability, and potentially active sham physiology can affect device-based autonomic trials. 5. Cannabis use and atrial arrhythmias: Systematic review and meta-analysis This large meta-analysis evaluates the association between recreational cannabis use and atrial arrhythmias, including atrial fibrillation, atrial flutter, atrial tachycardia, and SVT. The findings do not prove causality, but they make cannabis clinically relevant in arrhythmia history-taking, especially in younger patients, unexplained palpitations, AF, flutter, or SVT. 6. Postmyectomy hypertrophic cardiomyopathy: Residual sudden death risk This CMR-based cohort evaluates predictors of sudden cardiac death after surgical septal myectomy in obstructive HCM. The key clinical message is that myectomy can relieve obstruction, but it does not erase myocardial fibrosis, so late gadolinium enhancement remains important in ICD and surveillance discussions. 7. AF in HFpEF: Marker of ventricular tachyarrhythmia or cardiac arrest risk This study explores whether atrial fibrillation in HFpEF identifies patients at higher risk for ventricular tachyarrhythmias or cardiac arrest. It should not be interpreted as an ICD-indication study, but it raises an important hypothesis: AF in HFpEF may be a marker of deeper atrial-ventricular remodeling, fibrosis, autonomic dysfunction, or comorbidity clustering. 8. Long-term antithrombotic strategies after AF ablation: Network meta-analysis of randomized trials This analysis addresses one of the most practice-sensitive questions in AF management: whether anticoagulation can be safely stopped after apparently successful AF ablation. The signal is provocative, but the boundary remains narrow because event rates are low and high-risk patients remain underrepresented; this is a shared-decision paper, not a broad permission slip to stop OAC. 9. S/QRS ratio in lead I: ECG clue to pacemaker risk in RBBB This study examines whether the S-wave duration in lead I, expressed as a fraction of total QRS duration, can help identify patients with RBBB who may be at higher risk of requiring a pacemaker. The practical takeaway is simple: in RBBB, do not only measure QRS width—look carefully at lead I, because a short terminal S wave may suggest more diffuse His-Purkinje disease. Across all nine studies, the theme is consistent: modern electrophysiology is becoming more powerful, more data-driven, and more device-dependent, but the clinical edge still comes from judgment. EP Edge™ Journal Watch translates these studies into practical EP interpretation for electrophysiologists, cardiologists, EP fellows, APPs, and clinically engaged trainees. The full written issue, graphics, references, and subscription links are available through EP Edge™ Journal Watch on LinkedIn and Substack at epedge.substack.com.

EP Edge™ Journal Watch: AVANT GUARD Trial, PFA as First-Line Therapy for Persistent AF: Half the Story

In this special HRS 2026 edition of EP Edge™ Journal Watch, Dr. Niraj Sharma takes a deep, clinically focused look at the AVANT GUARD trial, published in The New England Journal of Medicine, evaluating pulsed field ablation as initial therapy for treatment-naïve persistent atrial fibrillation. AVANT GUARD delivered the headline many expected: first-line PFA reduced atrial arrhythmia recurrence and AF burden compared with antiarrhythmic drug therapy, with 12-month freedom from atrial arrhythmia of 56% versus 30%. But the story underneath is more complex. This episode examines why AVANT GUARD may influence future AF guidelines while also requiring careful interpretation. Dr. Sharma breaks down the trial design, including the randomized efficacy arm and the separate single-arm safety cohort, the exclusion of amiodarone from the comparator arm, the role of continuous monitoring, and why the primary efficacy result depends heavily on asymptomatic AF detection. The episode also explores the mid-trial safety pause after six neurological events, the post-pause protocol changes, the exclusion of patients with CHA₂DS₂-VASc ≥4, and the unresolved questions around female sex, stroke risk, and generalizability. Quality-of-life outcomes, symptomatic recurrence, adverse events, crossover to ablation, and patient counseling implications are reviewed in detail. Key topics include: Pulsed field ablation, persistent atrial fibrillation, AVANT GUARD trial, FARAPULSE, antiarrhythmic drugs, AF burden, asymptomatic AF recurrence, CHA₂DS₂-VASc, stroke risk, first-line AF ablation, HRS 2026, and electrophysiology trial interpretation. The EP Edge™ take: AVANT GUARD is a positive and important trial, but it is not a simple “PFA works twice as well” story. The trial supports first-line PFA for selected treatment-naïve persistent AF patients, but it does not prove superior symptom relief, quality-of-life improvement, or hard-outcome benefit at 12 months. Full references and graphics are available in the EP Edge Journal Watch LinkedIn newsletter and on Substack at epedge.substack.com