Abstract The management of persistent and long-standing persistent atrial fibrillation remains highly variable in clinical practice, despite increasingly refined guidelines and an expanding ablation armamentarium. Treatment sequencing is frequently driven by local program infrastructure and institutional culture, and hybrid ablation is often deferred until multiple endocardial procedures have failed, by which point progressive atrial remodeling may have already narrowed the therapeutic window. Randomized and registry data support a meaningful role for hybrid ablation earlier in the disease course of selected patients with non-paroxysmal AF, particularly those with enlarged atria, prolonged AF duration, advanced substrate, or failed prior endocardial ablation. Contemporary pulsed-field ablation technology has improved procedural safety and efficiency, yet freedom from recurrence at one year in persistent AF remains substantially lower than in paroxysmal AF across all current energy platforms, reflecting the complexity of atrial substrate over time. This ongoing myocardial remodeling places non-paroxysmal AF closer to a chronic structural cardiac disease than to a discrete procedural target and demands a lifetime management strategy rather than a sequence of isolated procedural decisions. The mindset for other progressive structural cardiac diseases has already moved in this direction—aortic valve stenosis is now managed through a multidisciplinary team that integrates anatomy, timing, procedural durability, and long-term risk across the full patient trajectory. We propose an AF Heart Team framework for non-paroxysmal AF in which catheter-based, hybrid, and surgical strategies are selected according to disease phenotype and lifetime trajectory, with the goal of intervening before advanced remodeling reduces the likelihood of durable rhythm control.
Abstract Oral anticoagulation has a very strong evidence base for stroke prevention in patients with atrial fibrillation (AF) at elevated thromboembolic risk. Direct oral anticoagulants have improved the safety and convenience of treatment, yet important limitations remain, including residual ischaemic stroke, major bleeding, treatment discontinuation, and patient refusal. Left atrial appendage closure (LAAC) offers an alternative strategy for selected patients by excluding the principal anatomical source of AF-related cardiac thrombi. However, the appropriate role of LAAC remains controversial, particularly in patients who can and do tolerate anticoagulation. This viewpoint argues for a more individualized approach that distinguishes absolute contraindications from modifiable bleeding risks, treatment refusal or non-persistence, and stroke occurring despite adequate anticoagulation.
Abstract The role of atrial fibrillation (AF) ablation in the management of heart failure with preserved ejection fraction (HFpEF) remains an under investigated issue with no robust clinical trials data. This controversy reviews the evidence for and against AF ablation in this complex condition from two different perspectives reviewing mechanistic and observational evidence aswell as proposing future directions for research in the field.
Abstract Background and Aims MODULAR ATP is an ongoing trial assessing the efficacy of a subcutaneous implantable cardioverter defibrillator (S-ICD) in communication with a leadless pacemaker (LP) that can deliver bradycardia pacing and antitachycardia pacing. The objective of this study was to assess safety and pacing performance of the investigational LP. Methods The study enrolled patients with an ICD indication and at high risk for monomorphic ventricular tachycardia. Pacemaker dependent patients were excluded. Primary safety endpoint 2 was the percentage of patients free from major LP-related complications at 12 months. The secondary effectiveness endpoint assessed the rate response performance of the LP under workload. Parameters related to the pacing performance were also measured. Results In 297 patients, the mean age was 59±12 years, the mean left ventricular ejection fraction was 35.3±13.1%, and 17.5% were female. LP implant was attempted in 286 patients and was successful in 100%. The major LP-related complication free rate at 12 months was 97.2% (one-sided 97.5% LCL 94.5%), surpassing the performance goal of 81%. There were no LP-related complications following Implant. For the secondary effectiveness endpoint, the slope of the normalized sensor rate versus the normalized workload was 0.96 (95% LCL 0.91, 95% UCL 1.02), within the performance goal range of 0.65-1.35. At 12 months, 96.8% of patients had a pacing capture threshold ≤ 2V @ 0.4ms pulse width. Conclusions The performance of the modular pacing-defibrillator system at one year demonstrated a low complication rate and reliable pacing functionality.
