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Aims: Loss-of-function (LOF) variants in SCN5A are associated with Brugada syndrome (BrS), progressive conduction slowing, and other arrhythmias. While the prognosis of SCN5A carriers with a positive sodium channel blocker challenge (SCBC) is established, data on those with negative SCBC are limited.

Objective: To assess the clinical presentation and prognosis of SCN5A variant carriers with negative SCBC, and compare them to relatives with positive SCBC.

Methods and results: We retrospectively included patients from five university hospitals (2000-2024) carrying a pathogenic or likely pathogenic SCN5A variant and negative SCBC. Relatives with the same variant and positive SCBC were also analysed. Patients with spontaneous type 1 ECG, gain-of-function variants, double variants, or ACMG class 1-3 variants were excluded. Clinical, ECG, genetic, and follow-up data were collected. Conduction slowing was evaluated using the PR interval and QRS duration. The cohort included 162 patients from 43 families (median age 37 ± 19 years, 46% male), of whom 69 (43%) had negative SCBC. Among these 69 patients, 25 (36%) had baseline intraventricular conduction defects, and 19 (28%) had first-degree AV block. After a median follow-up of 75 [40-168] months, 52% of patients developed progressive conduction slowing. Negative SCBC patients had fewer conduction defects (36% vs. 70%, p = 0.002) and ICD implantations (1% vs. 23%, P < 0.001). Non-missense variants were associated with more conduction slowing (71% vs. 42%, P = 0.04).

Conclusion: This multicentre study provides the largest analysis of SCN5A carriers with negative SCBC, showing excellent arrhythmic prognosis despite frequent progressive conduction slowing.

Aims: The clinical significance of early recurrences during the blanking period following pulmonary vein isolation (PVI) remains uncertain, particularly after pulsed field ablation (PFA). This study aimed to evaluate the prognostic impact of early recurrences at 30-, 60-, and 90-day thresholds on outcomes following PFA for atrial fibrillation (AF).

Methods and results: Consecutive patients who underwent PFA for AF across multiple centres within the Mayo Clinic health system were included. The primary endpoint was AF-free survival. Kaplan-Meier and multivariate Cox regression analyses were performed to compare outcomes between patients with and without early recurrences using 30-, 60-, and 90-day thresholds. A total of 1162 patients were included. The estimated AF-free survival at 1 year was 70%. Early recurrences within 30-, 60-, and 90-days post-ablation were significantly associated with late recurrences beyond 90 days (hazard ratio [HR] 5.9, 95% confidence interval [CI] 4.4-7.9, P < 0.01; HR 6.6, 95% CI: 5.0-8.6, P < 0.01; and HR 9.1, 95% CI: 7.0-11.7, P < 0.01, respectively). These findings remained significant among patients undergoing continuous rhythm monitoring. Early recurrences within 30 days in this subgroup were significantly associated with a 1-year AF burden >1% or the need for repeat AF ablation (odds ratio 25.0, 95% CI: 6.6-126.8, P < 0.01).

Conclusion: Early recurrences following PFA are strongly predictive of long-term arrhythmia recurrence and are unlikely to represent transient inflammatory phenomena. Accordingly, the applicability of the conventional blanking interval after PFA should be reconsidered.

In this narrative review, an example of a cardiac arrhythmia with a mechanistically appealing molecular pathomechanism is highlighted. This example will be used to delineate how recent basic science findings, which are summarized, can be used to obtain a deeper understanding of pathological behaviour from the molecular to the cellular level. The condition in question is the highly lethal catecholaminergic polymorphic ventricular tachycardia resulting from a point mutation of the cardiac ryanodine receptor. For this deep dive, the RyR2R420Q phenotype will be discussed in detail. Interestingly, these findings and the conclusions which could be drawn from them were very much unexpected but could be relevant for pharmacological treatments. To make the transition from the molecular and cellular findings to the patient will require the translation across several layers of complexity. Ultimately, such detailed understanding will lead to improved therapies tailored to each individual case and the specific RyR2 mutation carried by a particular family, in the framework of precision medicine.

Aims: Atrial fibrillation (AF) is conventionally classified as paroxysmal or persistent. AF burden might better reflect response to rhythm-control interventions. This study evaluated the association between estimated pre-procedural time spent in AF and recurrences after AF ablation, compared with conventional AF classification.

Methods and results: In patients scheduled for AF ablation, clinical characteristics were collected before ablation, and 60-second single-lead ECGs were recorded three times daily (with additional symptom-triggered recordings) for four weeks. Pre-procedural time spent in AF was estimated as the number of days with detected AF divided by total monitoring days. The primary endpoint was AF recurrence between 3 and 12 months post-ablation. Of 302 patients (mean age 64 ± 9 years; 33% female), 201 (67%) had paroxysmal AF and 101 (33%) had persistent AF. After 12 months, recurrence rates were higher in persistent than in paroxysmal AF (37.6% vs. 24.4%, P & 0.01) and in patients with a higher (>32%) vs. lower (≤32%) percentage of time spent in AF (36.4% vs. 24.0%, P < 0.01). Notably, paroxysmal AF patients with a higher percentage of time in AF had recurrence rates comparable to those of patients with persistent AF. Pre-procedural percentage of time in AF independently predicted arrhythmia recurrence at 12-month follow-up (HR: 1.06; 95% CI: 1.0-1.1; P & 0.025).

Conclusion: A higher pre-procedural percentage of time spent in AF derived from 60-second single-lead ECGs is independently associated with atrial arrhythmia recurrence after ablation. Assessing the percentage of pre-procedural time spent in AF might help identify paroxysmal AF patients with a high AF recurrence risk in future studies.

Aims: To examine and compare public procurement systems for electrophysiology (EP) consumables across 21 European countries, focusing on governance level, evaluation methods, clinician involvement, reimbursement variability, access to innovation and sustainability integration.

Methods: A qualitative, exploratory design was employed using 22 semi-structured interviews with EP clinicians, procurement specialists and health system stakeholders across 21 countries. Interview transcripts and summaries were thematically coded by two independent researchers using a structured six-domain framework.

Results: Substantial heterogeneity in procurement practices was identified. Hospital-level procurement predominates in 43% of countries, while 33% use regional-level tenders; a minority operate national-level frameworks. Evaluation methods vary, with several countries using price-driven criteria, while others apply mixed or clinically weighted models. Clinician involvement is high or moderate in two-thirds of countries, but often informal or lacking governance structure. Reimbursement for EP procedures varies widely in scope and transparency, with bundled and global budget models affecting innovation uptake. Innovation access remains uneven: countries such as Austria, the Netherlands and France use innovation funds or dedicated pathways, while others rely on centralized approvals or re-tendering. Sustainability criteria are rarely formalized in procurement decisions, despite growing awareness of environmental impact.

Conclusion: European procurement systems for EP consumables differ markedly in structure, evaluation practices and alignment with clinical and innovation priorities. Integrating clinician input, adopting value-based frameworks and embedding sustainability metrics could enhance procurement outcomes and patient care. Harmonized guidance from EHRA and EU-level stakeholders may support more equitable and innovation-friendly procurement strategies.

Aims: Cardiovascular-kidney-metabolic (CKM) syndrome reflects the interplay of cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic risk factors. We examined whether the number, components, and complexity of CKM domains influence outcomes and years of life lost (YLL) per death in patients with non-valvular atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs).

Methods and results: We included 17 378 AF patients (mean age 76.1 ± 10.7 years; 40.9% women) on DOACs from a multicentre Taiwanese database (2012-21). Patients were followed until outcomes, death, or study end. Overall, 18.1, 35.1, 32.2, and 14.6% of patients had 0, 1, 2, and 3 CKM domains. Women more often exhibited kidney, metabolic, or combined domains. Clinical risks rose stepwise with domain number; patients with three domains had the highest risks of ischaemic stroke/systemic embolic event/acute coronary syndrome (IS/SEE/ACS) [adjusted hazard ratio (aHR) 1.60, 95% confidence interval (CI) 1.25-2.05], major bleeding (aHR 2.60, 95% CI 2.00-3.38), heart failure hospitalization (aHR 2.83, 95% CI 2.38-3.37), all-cause mortality (aHR 1.80, 95% CI 1.58-2.06), acute kidney injury (aHR 3.42, 95% CI 2.76-4.25), and major adverse renal events (aHR 20.84, 95% CI 14.14-30.71; all P < 0.001). Domain-specific analysis showed kidney involvement conferred the strongest risks (except IS/SEE/ACS), while cardiovascular and metabolic domains were more associated with IS/SEE/ACS. YLL rose with more CKM domains, with females associated with greater reductions, especially in cardiovascular (-10.29 vs. -4.67) and metabolic (-4.98 vs. -0.80) domains (P < 0.001).

Conclusion: Increasing CKM burden was associated with progressively worse prognosis and shorter life expectancy in AF patients on DOACs, with more pronounced impacts in women.