BACKGROUND:Guidelines recommend a trial of antiarrhythmic drugs before catheter ablation for persistent atrial fibrillation. Whether pulsed field ablation (PFA) may be a preferred initial treatment is unclear. METHODS:We conducted an international, randomized trial involving patients with previously untreated persistent atrial fibrillation. The patients were randomly assigned in a 2:1 ratio to receive PFA performed with a pentaspline catheter or to receive antiarrhythmic-drug therapy. An additional group of patients (PFA-assigned) underwent PFA for the analysis of the primary safety end point alone. All the patients received an insertable cardiac monitor. The primary effectiveness end point was the short-term and long-term success of treatment through 12 months. Short-term success was defined as procedural success in the PFA group and the absence of ablation during the blanking period (90 days after treatment initiation) in the antiarrhythmic-drug group. Long-term success was defined as freedom from recurrence of atrial arrhythmias, repeat ablation, or need for antiarrhythmic drugs from 90 days through 12 months (in the PFA group) and freedom from amiodarone use at any time. The primary safety end point was device- and procedure-related serious adverse events. RESULTS:At 12 months, treatment success was observed in 128 of 207 patients (Kaplan-Meier estimate, 56%; 95% confidence interval [CI], 48 to 63) in the PFA group and in 40 of 103 patients (Kaplan-Meier estimate, 30%; 95% CI, 21 to 40) in the antiarrhythmic-drug group (hazard ratio for composite treatment failure [a lack of short- and long-term success], 0.46; 95% CI, 0.33 to 0.65; P<0.001). A primary safety end-point event occurred in 13 of 257 patients (5.1%) in the combined PFA group (both randomized and PFA-assigned groups). At 12 months, serious adverse events had occurred in 45 patients (25%) in the PFA group and in 20 patients (21%) in the antiarrhythmic-drug group. CONCLUSIONS:Among patients with persistent atrial fibrillation, the risk of recurrence of atrial arrhythmia was significantly lower among those who received PFA as first-line treatment than among those who received antiarrhythmic-drug therapy. (Funded by Boston Scientific; AVANT GUARD ClinicalTrials.gov number, NCT06096337.).
BACKGROUND:Pulsed field ablation (PFA) has emerged as a promising alternative to thermal catheter ablation for pulmonary vein isolation in atrial fibrillation (AF). OBJECTIVE:This study aimed to estimate the efficacy and safety of PFA vs thermal ablation in AF. METHODS:We searched PubMed, Embase, and Cochrane through July 2025 for studies comparing PFA with thermal ablation. Individual patient data were reconstructed from Kaplan-Meier curves, and hazard ratios were estimated using a Cox frailty regression model. Time to benefit was assessed to determine when the treatment effect became clinically meaningful. Study-level odds ratios and mean differences with 95% credible intervals were estimated fitting a Bayesian random-effects model and vague priors for overall effect in the primary analyses. RESULTS:12 studies (4 randomized controlled trials [RCTs], 8 observational) involving 3120 patients (46.6% PFA) were included. Time-to-event analysis (1 RCT, 6 observational) showed PFA was associated with a higher freedom from atrial tachyarrhythmia recurrence (hazard ratio 0.68; 95% credible interval 0.55-0.84). A time to benefit of 12 months was needed to prevent 5 atrial arrhythmia recurrences per 100 PFA-treated patients. In study-level analyses, the probability of a clinically meaningful reduction (odds ratio <0.8) in arrhythmia recurrence was 34.1% for RCTs and 96.5% for observational studies. PFA had a high likelihood of shorter procedural and left atrial dwell times. Safety outcomes showed no consistent excess risk with PFA. CONCLUSION:In patients with AF undergoing catheter ablation, PFA was associated with reduced arrhythmia recurrence compared with thermal ablation, with larger effects in observational studies and more modest effects in RCTs, and no signal of increased harm.
Abstract Background Dyslipidemia is known to be associated with an increased risk of cognitive impairment (CI). Studies have shown 1.23-fold higher risk of CI in patients with dyslipidemia vs without. Objective We investigated cognitive function in dyslipidemia patients treated with statin drugs vs those with normal lipid profile. Methods In this prospective study, consecutive patients attending our arrhythmia clinics for atrial fibrillation (AF) that were willing to undergo Montreal Cognitive Assessment (MoCA) at baseline and 1-year follow-up were enrolled in the DIAL-AF registry. In the MoCA survey, with a scale of 0-30, 27-30 is considered normal cognition, 18-26 as mild cognitive impairment (MCI) and ≤ 17 as dementia. Patients with baseline score of ≤17 were excluded from the analysis. DIAL-AF registry patients with dyslipidemia-on statin (DL group) were propensity matched 1:2 with those without dyslipidemia (non-DL group). Results A total of 125 patients from the DIAL-AF registry were included in the DL group and propensity-matched with 250 patients from the same registry without dyslipidemia (non-DL group). Clinical characteristics of the study population is provided in table 1. Baseline MoCA score was 26.03 ±2.41 in the DL-group vs 26.07±2.11 in the non-DL group (p=NS). At 1-year follow-up, mean MoCA score was significantly lower from the baseline score in the DL group (25.05±2.93, p<0.001) and higher (27.11±2.02, p<0.001) in the non-DL group (figure 1). Mean change in the score was -0.98±2.71 and 1.04±2.07 in the DL and non-DL group respectively (p<0.001). In the multivariable regression analysis, dyslipidemia on statin therapy was found to be a predictor of cognitive decline (Odd’s Ratio = 1.471; 95% CI 1.101 – 2.814; P-value = 0.027). Conclusion In AF patients with dyslipidemia, significant cognitive decline was evident despite being on statin therapy, whereas the MoCA score improved in the non-DL group.
Description This painting depicts young Asclepius under the guidance of Chiron, the wise centaur renowned for his knowledge of healing and medicine. In Greek mythology, Asclepius was entrusted to Chiron after Apollo recognized his potential. Within the nurturing environment of Chiron's home, Asclepius absorbed lessons on the use of medicinal herbs, wound treatment, and the foundational principles of care, skills that would eventually elevate him to become the Greek God of Medicine. The herbs symbolize hands-on learning and the practical foundation of healing, while the book signifies the accumulation and sharing of knowledge, showing how medical innovation progresses through study, collaboration, and the passing of wisdom. It's not just the transfer of knowledge, but the intentionality and patience in Chiron's teaching, mirrored in Asclepius's focused and reverent attention. This scene illustrates the timeless impact of mentorship and deliberate instruction. It shows that mastery is not instant but cultivated through observation, practice, and careful guidance. The relationship between teacher and student is depicted as a partnership in growth, emphasizing that the development of skill and wisdom requires patience, trust, and attentive presence. Medicine is not merely a collection of facts, but a craft honed through experience and human connection. The painting captures the essence of how knowledge is passed from teacher to student, highlighting the enduring importance of mentorship in shaping not only skill, but character and empathy.
