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Aims: Leadless pacemakers (LLPs) offer a valuable option for selected patients requiring ventricular pacing. However, data on revision procedures-defined as any intervention on an implanted LLP to correct dysfunction or upgrade the system, with or without removal-remain scarce. This study aimed to evaluate the real-world incidence, characteristics, and outcomes of LLP revisions, with particular emphasis on the feasibility and safety of removal.

Methods and results: This multicentre retrospective study involved 46 French centres performing LLP implantations between 2015 and 2023. Among 8994 Micra LLPs implanted, 100 revision procedures (1.1%) were performed in 100 patients, including 73 Micra VR and 27 Micra AV devices, at a median follow-up of 229 (68.5-629.8) days. Seventy revisions were managed without device removal, while 30 involved removal. Revision indications included device upgrade (55%), high pacing threshold (33%), battery depletion (3%), ventricular arrhythmias (3%), and miscellaneous causes (6%). No significant differences were observed in pacing indications, implantation characteristics, or initial device indication between the two groups. Revisions occurred significantly earlier in the removal group than in the group without removal [median 81.5 (8-211.5) days, vs. 334 (130.25-882.5) days, P < 0.001], with 80% occurring within 1 year. Device removal was successful in 97% of cases (one failure at 157 days of follow-up), with no major complications reported.

Conclusion: LLP revisions are infrequent and predominantly managed without device removal. However, given the high procedural success rate and the low complication rate, device removal appears to be underutilized and should be considered more frequently on a case-by-case basis.

Aims: Atypical atrial flutter (AAFl) encompasses a diverse group of macro-reentrant arrhythmias with variable circuits, presenting diagnostic and therapeutic challenges. This European Heart Rhythm Association (EHRA) survey aimed to assess current practices across European centres regarding the management of AAFl.

Methods and results: A 26-item online questionnaire distributed by the EHRA Scientific Initiatives Committee yielded 214 responses from physicians in 36 countries. Catheter ablation was considered first-line therapy by 67.6% of respondents. In patients presenting in sinus rhythm with non-inducible clinical AAFl at the time of ablation, management strategies were heterogeneous, with combined pulmonary vein isolation and substrate ablation being the most common approach (46.8%). Activation mapping was the preferred method to define the circuit (63.7%), ahead of entrainment manoeuvers. Most respondents (87.1%) used ablation lines connecting scar or unexcitable tissue, whereas only 7.5% targeted the critical isthmus alone. The most frequent endpoints were validation of conduction block (73.1%), interruption of the clinical arrhythmia (71.0%), and non-inducibility of the clinical flutter (56.5%), while non-inducibility of any atrial flutter was rarely pursued. In patients without prior cardiac intervention, the left atrial anterior wall was perceived to be the most frequently involved structure (59.4%). Finally, in case of recurrence, 74.3% of respondents preferred redo ablation.

Conclusion: This EHRA survey reveals consensus on ablation endpoints but marked variability in ablation timing and strategies when AAFl is non-inducible at the time of ablation, underscoring the need for standardized protocols and further collaborative research to optimize outcomes.

Aims: Atrial fibrillation (AF) and cancer are both highly prevalent conditions and are known to be associated. Our aim was to identify predictors and develop models for all cancer types, in men and women, and for the four most common cancer types in the AF population using linked primary and secondary care data from the UK.

Methods and results: We included 163 549 patients diagnosed with AF between January 1998 and May 2016, and no previous history of cancer. Following TRIPOD methodology, we developed a ridge-penalized multivariable logistic regression model to predict 1-year cancer incidence after AF diagnosis, using 70% of the data for derivation and 30% for validation. Age was associated with an increased risk across all cancer types. Socioeconomic deprivation, smoking, excessive alcohol intake, family history of cancer, chronic kidney disease, anaemia, and several cancer-related symptoms and clinical signs (e.g. rectal bleeding, loss of appetite) were associated with an increased risk in one or more cancer types. The prediction models showed moderate-to-good discrimination in the validation set, with c-statistic of 0.69 (0.68-0.70) for all cancer in men, 0.63 (0.62-0.65) for all cancer in women, 0.70 (0.68-0.73) for lung cancer, 0.70 (0.66-0.73) for colorectal cancer, 0.59 (0.53-0.65) for breast cancer, and 0.78 (0.72-0.84) for prostate cancer.

Conclusion: Most of the identified potential risk factors for cancer in the AF population are also associated with cardiovascular disease. The 1-year cancer prediction models showed moderate to good predictive performance and may help improve the management of patients with AF.

Cardiac implantable electronic device upgrade and downgrade procedures are increasingly being performed. Whilst the most appropriate guideline-recommended device may have been followed during a patient's initial procedure, the requirements of patients can change over time. This could be due to worsening of cardiac function due to detrimental effects of pacing itself or the diagnosis, development, or progression of another cardiac comorbidity. Device downgrades are also performed when a patient's clinical state changes and are often considered in patients with increased frailty and comorbidity. This clinical consensus statement aims to provide a framework for screening patients for device upgrade, pre-procedural planning considerations, available procedural strategies, namely a summary of techniques and approaches for vascular access, including ipsilateral and contralateral options, and a framework for when extraction to gain access may be appropriate. The document also provides advice on how to frame an ethical discussion with patients and carers on available options.

Aims: Antiarrhythmic drugs are used during cardiopulmonary resuscitation (CPR) to improve the chances of return of spontaneous circulation (ROSC) in shockable rhythms. To date, their impact on clinical outcomes remains uncertain. This review aimed to provide an evaluation of respective up-to-date evidence.

Methods and results: We searched Embase, MEDLINE®, and Cochrane Central Register of Controlled Trials. Data on study design, population characteristics, antiarrhythmic drugs used, and predefined outcomes were extracted. A meta-analysis was conducted in groups with at least three studies reporting the same outcome. Additionally, we performed subgroup analysis according to the study design. Initially, 5080 studies were identified, and 29 were included, with, in total, 60 205 patients. A statistically significant difference in achieving ROSC was found comparing (i) lidocaine and no lidocaine, favouring lidocaine [odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.11-2.32, P = 0.01]; (ii) nifekalant and lidocaine, favouring nifekalant (OR = 4.18, 95% CI: 2.23-7.83, P < 0.00001); and (iii) esmolol and no esmolol, favouring esmolol (OR = 3.0, 95% CI: 1.40-6.40, P = 0.005). For the effect on survival to hospital discharge, a significant difference between lidocaine and no lidocaine, favouring lidocaine (OR = 1.66, 95% CI: 1.02-2.7, P = 0.04), was found.

Conclusion: Evidence supporting the use of any antiarrhythmic drugs during CPR remains limited and is partly inconclusive. For the effect on survival to hospital discharge, a statistically significant difference was only found favouring the administration of lidocaine compared to no lidocaine. Further research with improved trial design and into novel drug options should be conducted.

Atrial tachycardias (AT) represent an increasingly recognized cause of morbidity and mortality. Over the past decade, the mechanistic understanding and therapeutic concepts guiding AT treatment have undergone rapid progress. Catheter ablation has become the most effective therapy for maintaining sinus rhythm in patients with regular AT, while mapping and ablation concepts and technologies have improved significantly. Accordingly, international cardiac electrophysiology professional societies aimed at outlining best practices on the management of regular AT, with a special focus on indications, timing, and technical aspects of AT mapping and ablation. After reviewing and discussing available evidence, including a systematic literature review and meta-analysis, an expert writing group summarized current knowledge and practice and has proposed strategies in the here outlined 10-Point Plan for SMART-AT care (Standardized Management and Ablation Roadmap for Treatment of Patients with Atrial Tachycardia).

Pulsed field ablation (PFA) represents one of the most significant technological advances in atrial fibrillation (AF) therapy in recent decades. By harnessing irreversible electroporation, PFA produces myocardial lesions within milliseconds, enabling rapid and efficient pulmonary vein (PV) isolation. Early clinical experience from pivotal investigational device exemption (IDE) trials has shown acute and one-year arrhythmia-free outcomes that are non-inferior to conventional radiofrequency (RF) and cryothermal ablation. The large MANIFEST-17 K registry, encompassing over 17 000 patients treated with the Farawave system, reported an exceptionally low 0.98% major complication rate with no atrio-oesophageal fistula, phrenic nerve injury, or PV stenosis. These findings have accelerated PFA adoption across many centres. However, as experience broadens, nuances in lesion formation and durability are becoming evident. Factors such as contact force, catheter rotation, pulse train configuration, and target tissue geometry influence lesion depth and transmurality. While PV isolation appears consistently durable, data remain limited for non-PV targets such as the posterior wall, mitral isthmus, and cavotricuspid isthmus. Moreover, novel PFA-specific complications including transient left atrial dysfunction, haemolysis, and coronary artery spasm warrant ongoing vigilance. PFA has undoubtedly transformed expectations for procedural safety and efficiency. Yet whether it should already be considered the standard technique for all AF ablation candidates remains an open question. This Controversy piece explores the balance between innovation and evidence, examining whether PFA's rapid rise represents the inevitable new standard or a technology still undergoing critical refinement.

Aims: Anatomical studies have documented a close topographical relationship between the ganglionated plexi (GP) containing parasympathetic inputs to the sinus node (SN) and atrioventricular node (AVN) and the epicardial fat pads (FPs) within the Waterston's interatrial groove. We aimed to investigate the feasibility and outcomes of a novel anatomical approach to cardioneuroablation (CNA) that targets the atrial areas adjacent to the interatrial FPs identified with intracardiac echocardiography (ICE).

Methods and results: About 17 patients [37.3 ± 10.2 years, 47% female] undergoing CNA for recurrent vasovagal syncope and documented sinus pauses (n = 13, 76%) and/or AVN block (AVB, n = 4, 16%) were included. The right superior RS-FP containing the RS-GP (target for SN vagal denervation) and the right inferior RI-FP containing the RI-GP (target for AVN vagal denervation) were identified with ICE and reconstructed on a 3D electroanatomic map. At baseline, all patients had provocable sinus pauses/AVB with extracardiac high-frequency vagal stimulation (ECVS). The target FPs could be identified in all patients and were adjacent to septal LA and RA sites covering an average surface area of 3.7 ± 1.4 cm2 and 2.97 ± 1.21 cm2, respectively. A total of 33 ± 15 RF ablations (30-40W, 60 s) were delivered to cover the target LA/RA area. A > 25% shortening of the PP interval was observed within the first 1-2 RF lesions in all cases. After ablation, complete abolition of sinus pauses/AVB response with ECVS was achieved in all patients, and 2 mg of atropine infusion resulted in no PP/PR interval change. After a median follow-up of 12 months (range 4-25 months), 16 patients (94%) remained free of recurrent symptoms (1 patient underwent repeat CNA for recurrent pre-syncope and AVB, 1 patient underwent PPM implant following ECG recording of asymptomatic diurnal AVB).

Conclusion: An ICE-guided anatomical approach to CNA targeting visible FPs at the Waterston's groove is a feasible and effective strategy to achieve SN/AVN vagal denervation, with good outcomes at mid-term follow-up.