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Aims: Clinical complexity (CC) in atrial fibrillation (AF) reflects overlapping risk factors that raise vulnerability to both thromboembolism and bleeding. Ethnic differences in the expression of CC remain poorly characterized.

Methods and results: We performed a post hoc analysis of the EORP-AF and APHRS-AF registries. CC was defined as a CHA₂DS₂-VASc score ≥2 plus ≥1 of: (i) age ≥75 and BMI <23 kg/m², (ii) chronic kidney disease, or (iii) prior major bleeding. Multivariable logistic regression identified predictors of CC, oral anticoagulant (OAC) use, and rhythm control. The primary outcome was a composite of all-cause death and major adverse cardiovascular events (MACE), defined as cardiovascular death, acute coronary syndromes, and thromboembolic events. Secondary outcomes included each individual component and major bleeding. Associations were assessed using Cox regression models. Among 14 055 patients, 2794 (19.9%) met CC criteria (mean age 77 ± 9 years; 46% female). Compared to Europeans, Asian patients with CC had a distinct clinical profile and were less likely to receive OAC (OR 0.75, 95% CI 0.57-1.01) or rhythm control (OR 0.53, 95% CI 0.41-0.69). CC was independently associated with increased risk of composite outcome (HR 1.55, 95% CI 1.35-1.77), all-cause death (HR 1.65, 95% CI 1.42-1.93), MACE (HR 1.50, 95% CI 1.26-1.80), cardiovascular death (HR 1.81, 95% CI 1.40-2.36), and major bleeding (HR 2.02, 95% CI 1.47-2.77). The excess risk of the composite outcome was greater in Asians (HR 2.28, 95% CI 1.57-3.32) than in Europeans (HR 1.51, 95% CI 1.31-1.75; P-interaction = 0.036).

Conclusion: Among AF patients with CC, those enrolled in Asia exhibited marked differences in clinical profiles, management strategies, and outcomes, suggesting greater vulnerability to CC in the Asian population.

Aims: Despite technical advances, transvenous lead extraction (TLE) remains a challenging procedure. Cardiac computed tomography (CT) has emerged as a valuable tool for pre-procedural assessment, but its role in predicting outcomes in rotational mechanical TLE as a first-line strategy is not well defined. The aim was to determine whether pre-procedural CT can predict complications and procedural complexity in patients undergoing rotational mechanical TLE.

Methods and results: This retrospective study included 115 patients. All had pre-procedural contrast-enhanced CT with a dedicated lead extraction protocol. Two procedural outcomes were evaluated: (i) complicated procedure, defined as major complication, incomplete lead removal, or snare use, and (ii) complex procedure, defined as requiring either a snare or a tissue stabilization sheath. Logistic regression and receiver operating characteristic analyses were used to identify predictors. A total of 215 leads were extracted (mean dwelling time 95 ± 73 months). Complicated procedures occurred in 20.9% and were independently associated with longest fibrosis length on CT (odds ratio 1.1; P < 0.001); a fibrosis length of >40 mm predicted complicated procedures [area under the curve (AUC) 0.92; 95% confidence interval (CI) 0.88-0.97]. Complex procedures occurred in 37.4% and were associated with longest fibrosis length, lead calcification, dwelling time, and systolic heart failure. A fibrosis length of >30 mm predicted complex procedures (AUC 0.72; 95% CI 0.64-0.81).

Conclusion: Pre-procedural CT allows accurate identification of high-risk anatomical features, particularly fibrosis length and calcifications, which independently predict both complicated and complex rotational mechanical TLE. These findings support the integration of CT imaging into procedural planning and individualized risk stratification.

For patients with heart failure (HF) and bundle branch block, cardiac resynchronization therapy (CRT) by biventricular pacing (BiVP) has been found effective and has been widely used for around 20 years. The effects of BiVP are well documented in a row of large randomized controlled trials (RCTs) with long-term follow-up to include prolonged survival, less HF hospitalizations, and better quality of life for the patients. More recently, conduction system pacing (CSP) as His bundle pacing or left bundle branch area pacing has been introduced for CRT and shown to in best cases establish a normal or near-to-normal electrical activation of the left ventricular myocardium. Data from large RCTs documenting the beneficial effects of CSP are awaited. Currently, the question is to what extent the contemporary literature supports a transition from BiVP to CSP for CRT in patients with HF and bundle branch block. This Europace Controversy article presents opposing viewpoints on this topic. H.B., M.J., and J.J. argue in favour of CSP being superior to BiVP. Conversely, C.L., N.B., and J.C.D. advocate for BiVP still being the first choice for CRT. This Controversy aims to present data and their interpretation from different expert perspectives on an important topic in CRT for HF.

Background: With the introduction of pulsed field ablation (PFA) to treat atrial fibrillation (AF), there is interest in studying workflow and sedation strategies to optimize integration into clinical practice. This sub-analysis characterizes early real-world use of general anesthesia versus deep sedation during AF ablation using the pentaspline PFA catheter.

Methods: EU-PORIA is an all-comer AF registry enrolling consecutive patients at seven high-volume centers in Europe. Patients were treated based on institutional standard-of-care. During follow-up, any episode of atrial tachycardia (AT) or AF >30s was considered an arrhythmia recurrence.

Results: EU-PORIA enrolled 1233 patients, of which 250 (20%) and 983 (80%) cases were performed using general anesthesia and deep sedation, respectively. Patients treated with general anesthesia were more often male and non-paroxysmal AF. In the general anesthesia group, 72% received pulmonary vein isolation (PVI)-only versus 90% in the deep sedation group (p<0.01), and 3D mapping was used in 60% of general anesthesia and 27% of deep sedation cases (p<0.01). Procedure and fluoroscopy times were shorter with deep sedation (51[36-84] vs 75[60-90] min; 13[8-19] vs 19[15-26] min; p<0.01). There were no differences in the incidence of serious adverse events. At 1-year follow-up, 74.8% and 73.8% of patients in the general anesthesia and deep sedation groups, respectively, were free from recurrent AF/AT (p=0.87).

Conclusion: AF ablation using deep sedation with the pentaspline PFA catheter demonstrated a safety and efficacy profile consistent with procedures performed under general anesthesia. This characterization of real-world use warrants further evaluation to understand optimal sedation strategies with PFA technologies.

Background: Wearable ECG-enabled smartwatches have been validated for atrial fibrillation (AF) screening, but their accuracy for monitoring AF recurrence and quantifying AF burden after catheter ablation is uncertain.

Objectives: To evaluate the simulated performance of three commercial smartwatch algorithms for AF recurrence detection and AF burden estimation compared with implantable cardiac monitors (ICMs).

Methods: Using continuous ICM data from 346 patients in the CIRCA-DOSE trial, we simulated three smartwatch algorithms, assuming daytime wear (8:00 AM-10:00 PM). We also simulated commonly-used non-invasive intermittent rhythm monitoring strategies. Primary endpoints were sensitivity for arrhythmia recurrence and correlation with ICM-derived AF burden. Analyses were stratified by daily wear time and patient activity.

Results: AF recurrence occurred in 47.1% of patients. Simulated detection sensitivities were 82.2% (Apple Watch AF Burden), 70.6% (Apple Watch IRN), and 64.4% (Fitbit IHRD), compared with 15.8%-64.6% for simulated intermittent AECG monitors. Wearables outperformed commonly-used Holter/patch monitoring strategies. AF burden correlation with ICM exceeded r = 0.97 for all algorithms. Among missed recurrences, median AF burden was <0.02%. Longer daily wear improved sensitivity (>90% with 24-hour use), whereas patient activity modestly reduced detection.

Conclusions: Smartwatch-based AF detection algorithms demonstrate strong correlation with ICM-derived AF burden and clinically good sensitivity for recurrence detection, outperforming conventional non-invasive strategies. These findings support the integration of wearables as a scalable alternative for post-ablation rhythm monitoring.

Aims: The direct oral anticoagulant (DOAC) score was recently developed to predict bleeding risk in patients with atrial fibrillation (AF) receiving oral anticoagulants. However, limited data show inconsistent results comparing its performance to the conventional HAS-BLED score in Asian populations with non-valvular AF receiving DOACs.

Methods and results: We enrolled 21 142 patients with non-valvular AF receiving DOACs from a multicentre database in Taiwan (June 2012-December 2021). The primary endpoint was major bleeding events. Major bleeding events were defined according to the ISTH criteria. Areas under receiver operating characteristic curves (AUCs) were calculated for each score, with differences assessed using DeLong test. A total of 21 142 AF patients (mean age 75.9 ± 11.0 years; 41% female) treated with DOAC were included in the analysis. Major bleeding events occurred in 681 patients in 1-year follow-up (3.66%/year). There were 82(0.43%/year) intracranial haemorrhage event occurred. Both the DOAC and HAS-BLED scores are associated with a significant risk of major bleeding event, with only modest predictive performance (AUC < 0.7). The DOAC score showed a slightly but statistically significantly higher AUC compared with the HAS-BLED score [AUC: 0.670 (95% CI: 0.650-0.689) vs. 0.642 (0.623-0.663); P < 0.001]. Results from several reclassification analyses favoured the DOAC score. Both the two scores showed a good calibration for the low to intermediate risk categories, while the two bleeding risk scores both overestimate the risk of major bleeding risk for the high risk categories. Subgroup analyses indicated that the superiority of DOAC score over HAS-BLED score is primarily driven by elderly patients (≥75 years) and prediction in risk of gastrointestinal bleeding.

Conclusion: The DOAC score, which employs a more granular scoring system compared to the HAS-BLED score, may enable finer bleeding risk discrimination among Asian patients with non-valvular AF receiving DOAC therapy.