What defines successful atrial fibrillation ablation: fewer recurrences, lower AF burden, better quality of life, or all three? In this ESC Congress 2026 special issue of EP Edge Journal Watch, Dr. Sharma examines evidence from Munich, Germany, August 28–31, 2026, alongside previously covered sham-controlled trials to explore what meaningful patient benefit should look like.

PVI-SHAM-AF leads the discussion. Rolf Wachter and colleagues found lower sampled atrial fibrillation burden after catheter ablation, but no demonstrated superiority over sham on the primary Atrial Fibrillation Effect on Quality-of-Life (AFEQT) endpoint. We examine the primary result, the favorable sensitivity analysis, and why failure to demonstrate superiority does not establish equivalence.

PFA-SHAM and SHAM-PVI provide the earlier evidence. These trials demonstrated additional patient-reported benefit with pulsed field ablation and cryoballoon pulmonary vein isolation, respectively. Their differing populations, endpoint priorities, and monitoring methods help frame the comparison, without implying that one ablation technology is superior to another.

Our In Depth synthesis examines baseline symptom severity, possible ceiling effects, recruitment, cardioversion, antiarrhythmic management, beta blockers, and continuous versus intermittent rhythm monitoring. These are potential contributors to the discordant findings, not established explanations. Drawing on Andrea Natale’s review, the Marrouche–Glotzer editorial, and Dulai’s SHAM-PVI substudy, we distinguish rhythm recurrence from residual burden, symptoms, functional improvement, and treatment burden. What should count as clinical success, and which definitions still need prospective validation?

FlexPulse follows with 12-month results for focal dual-energy radiofrequency and pulsed field ablation. We review 74.6% composite effectiveness, safety, redo-mapping findings, and the substantial effect of monitoring intensity on apparent success. Single-arm results and retrospective lesion-quality associations are not comparative proof.

NEXAF examines structured exercise in AF care. A supervised-to-home exercise program reduced continuously monitored AF burden by 45% relative to usual care, but did not demonstrate superiority on the quality-of-life co-primary endpoint.

IDEAL-AF evaluates individualized low-voltage substrate ablation in selected patients with persistent AF. We discuss improved rhythm outcomes beyond pulmonary vein isolation, patient selection, verified electrical endpoints, and the accompanying Kistler–Chieng editorial. The findings do not justify routine additional lesions in every patient.

ENRICH-AF closes with edoxaban after intracranial hemorrhage. Fewer ischemic strokes were accompanied by more hemorrhagic strokes and major bleeding, without demonstrated superiority on the primary stroke or systemic embolism endpoint.

NEXAF and ENRICH-AF are discussed as congress-results reports, not full results manuscripts. Designed for electrophysiologists, cardiologists, trainees, researchers, and cardiovascular care teams, this episode connects trial interpretation with patient counseling, medication review, and shared decision-making.

Explore the complete newsletter, infographics, and references, and follow EP Edge Journal Watch for weekly electrophysiology analysis.

In this special edition of EP Edge® Journal Watch, Dr. Sharma reviews the major breaking cardiovascular and electrophysiology science presented at the European Society of Cardiology Congress 2026 in Munich.

The episode begins with two important electrophysiology trials that challenge familiar clinical thresholds.

First is SINGLE-AF, led by Daehoon Kim and colleagues and published in the New England Journal of Medicine in August 2026. The trial provides the first randomized evidence evaluating direct oral anticoagulation versus no anticoagulation in patients with atrial fibrillation at intermediate stroke risk. Dr. Sharma explains why this population has remained a clinical gray zone, how the trial was designed, what the 69% relative reduction in the primary net clinical endpoint actually means, why the absolute event rate remains important, and whether these findings should change anticoagulation decisions in everyday AF practice.

Next is CMR GUIDE, led by Joseph B. Selvanayagam and colleagues and published in JAMA in August 2026. This provocative randomized trial tested whether myocardial scar identified by late gadolinium enhancement cardiac MRI could help identify patients with LVEF 36% to 50% who may benefit from a primary-prevention ICD. Although the primary endpoint was neutral, the reduction in sudden cardiac death and the striking signal among patients younger than 70 years raise a much larger question for electrophysiologists: Is LVEF alone still an adequate way to determine sudden cardiac death risk and ICD candidacy?

The episode then moves into a rapid review of additional major developments from ESC 2026.

The 2026 ESC Heart Failure Guidelines, led by Lars Køber, Marianna Adamo and colleagues and published in the European Heart Journal, eliminate the traditional HFmrEF category, redefine HFrEF as LVEF below 50%, introduce a Stage A through D heart failure framework, and reorganize therapy into foundational, additional, and guideline-directed interventional treatment. Dr. Sharma discusses why this major change in heart failure classification does not automatically change ICD or CRT indications, but may influence how future device therapy is studied.

The Fifth Universal Definition of Myocardial Infarction, led by Nicholas Mills, L. Kristin Newby, Sarah Zaman and colleagues, introduces a simpler pathophysiologic classification of primary MI, secondary MI, and procedure-related MI. Of particular relevance to electrophysiology, the new framework may help clarify how elevated troponin should be interpreted in patients with rapid atrial fibrillation and other tachyarrhythmias, separating true ischemic myocardial infarction from acute myocardial injury.

Also discussed is the major Nature Reviews Cardiology review led by Thomas Münzel and colleagues examining nicotine and cardiovascular disease. The review places combustible cigarettes, heated tobacco products, e-cigarettes, and oral nicotine products along a continuum of cardiovascular harm and emphasizes that reduced exposure to combustion does not make nicotine-containing products cardiovascularly neutral.

Finally, Dr. Sharma examines an innovative study presented by Viana Copeland and colleagues using artificial intelligence to analyze nearly 100,000 mammograms for cardiovascular signals associated with hypertension, ischemic heart disease, and stroke. The concept raises the intriguing possibility that imaging obtained for one clinical purpose may ultimately provide useful information about entirely different disease phenotypes.

Throughout the episode, the emphasis is not simply on reporting trial results. Dr. Sharma explains why each study was needed, how it was designed, what the statistics actually mean, what the limitations are, and how the findings may influence clinical electrophysiology practice.

Topics include:

•  ESC Congress 2026 Munich 
•  SINGLE-AF trial 
•  atrial fibrillation and anticoagulation 
•  CHA₂DS₂-VA and intermediate stroke risk 
•  DOAC therapy 
•  CMR GUIDE trial 
•  cardiac MRI and late gadolinium enhancement 
•  myocardial scar and sudden cardiac death 
•  primary-prevention ICD therapy 
•  LVEF greater than 35% 
•  2026 ESC Heart Failure Guidelines 
•  HFrEF and HFpEF 
•  Fifth Universal Definition of Myocardial Infarction 
•  Type 2 MI and tachyarrhythmias 
•  nicotine and cardiovascular disease 
•  vaping and cardiovascular risk 
•  artificial intelligence in cardiovascular imaging 
•  AI mammography and cardiovascular screening 
•  cardiac electrophysiology 
•  sudden cardiac death risk stratification 

For the full statistical analysis, references, figures, and graphics, read EP Edge® Journal Watch on LinkedIn and Substack at epedge.substack.com.

Questions, suggestions, or concerns: [email protected].

In this EP Edge and Heart Rhythm Society collaborative podcast, Dr. Niraj Sharma and Dr. Mike Lloyd examine new evidence challenging several long-standing assumptions in cardiac electrophysiology: when to choose catheter ablation over antiarrhythmic drug therapy for atrial fibrillation, whether left bundle branch area pacing should replace conventional right ventricular pacing in patients who require substantial ventricular pacing, and how broadly the lessons of CAST should continue to restrict flecainide and other Class Ic antiarrhythmic drugs.

The atrial fibrillation discussion brings together two complementary 2026 Heart Rhythm meta-analyses. Demy L. Idema and colleagues evaluated antiarrhythmic drugs versus catheter ablation for rhythm control across randomized controlled trials, focusing on AF recurrence, hospitalization, mortality, and treatment-related complications. Marwan Shawki and colleagues examined the safety of catheter ablation versus antiarrhythmic drugs across 24 randomized trials involving 6,665 participants. Together, the studies raise an important contemporary question: as ablation becomes more effective and procedural safety improves, does antiarrhythmic drug therapy still deserve an automatic position ahead of ablation in the AF treatment pathway?

The discussion then turns to physiologic pacing and the PACE-HF trial by Jenish P. Shroff and colleagues, published in the European Heart Journal. In this prospective randomized trial, left bundle branch area pacing was compared with conventional right ventricular pacing in patients with preserved or mildly reduced left ventricular ejection fraction who were expected to require substantial ventricular pacing. The trial provides randomized evidence on ventricular function, pacing burden, heart failure hospitalization, and the potential consequences of chronic nonphysiologic right ventricular activation.

Finally, the podcast revisits flecainide more than three decades after the Cardiac Arrhythmia Suppression Trial (CAST). The discussion incorporates the systematic review by Li and colleagues in Heart Rhythm examining how CAST reshaped flecainide research and clinical use, together with the nationwide cohort study by T.-C. Huang and colleagues in Heart Rhythm evaluating Class Ic antiarrhythmic therapy after PCI in patients with new-onset atrial fibrillation. The central question is not whether CAST was correct in the post-myocardial-infarction population it studied, but whether its findings have been extrapolated too broadly to contemporary patients with stable or revascularized coronary disease, preserved ventricular function, and atrial rather than ventricular arrhythmias.

Across atrial fibrillation ablation, conduction-system pacing, and Class Ic antiarrhythmic therapy, the episode asks a common question: when new evidence challenges an established electrophysiology default, when is the evidence strong enough to change everyday practice?

Studies Discussed

Idema DL, et al. Antiarrhythmic drugs vs catheter ablation as rhythm control for atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials. Heart Rhythm. 2026;23:1465-1475.

Shawki M, et al. Safety of catheter ablation compared with antiarrhythmic drugs for atrial fibrillation: A systematic review and meta-analysis of randomized trials. Heart Rhythm. 2026;23:1453-1464.

Shroff JP, et al. Left bundle branch area pacing vs right ventricular pacing in preserved or mildly reduced ejection fraction: the PACE-HF trial. European Heart Journal. 2026;47:3298-3300.

Li et al. Flecainide use before and after the Cardiac Arrhythmia Suppression Trial: A systematic review. Heart Rhythm. 2026.

Huang TC, et al. Class Ic antiarrhythmic therapy after PCI in new-onset atrial fibrillation: Safety and clinical outcomes from a nationwide cohort. Heart Rhythm. 2026;23:e1372-e1382.

What can nine carefully selected studies teach us about the changing practice of cardiac electrophysiology?

In EP Edge® Journal Watch Issue 34, August 2026, Dr. Sharma provides a clinically focused review of emerging evidence across atrial fibrillation, pulsed field ablation, implantable cardiac devices, sudden death prevention, resuscitation, occupational radiation safety, and postural orthostatic tachycardia syndrome.

This episode examines whether transvenous and subcutaneous ICD shocks produce different patterns of myocardial injury; the incidence and clinical meaning of migraine following pulsed field ablation; whether routine mechanical CPR improves meaningful survival after out-of-hospital cardiac arrest; and why hemolysis and renal effects may differ among PFA platforms and workflows.

Dr. Sharma also explores the FINE-HEART analysis of finerenone and sudden death, the LOSE-AF randomized trial of weight loss in older patients with persistent atrial fibrillation, occupational radiation exposure during pregnancy, the prognostic significance of skin thickness over cardiac implantable electronic devices, and a randomized crossover comparison of ivabradine and propranolol for POTS.

Rather than simply reciting percentages and P values, the discussion explains why each study was undertaken, how it was designed, what its principal statistical findings mean, where uncertainty remains, and how the results might—or might not—affect clinical practice. Each analysis concludes with the EP Edge take: a practical interpretation for physicians, trainees, nurses, allied professionals, and others caring for patients with heart-rhythm disorders.

The episode also previews the early September 2026 arrival of EPEdge.org and the EP Edge app. Built around Knowledge · Access · Humanity, the new platform will bring together EP Edge Analytics, EP Edge Academy, CME and MOC opportunities, EP Edge Rx, practical clinical resources, and the complete EP Edge newsletter archive.

And don’t miss next week’s must-listen collaborative issue with the Heart Rhythm Society.

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How long should anticoagulation continue after an apparently successful atrial fibrillation ablation? Should prophylactic pulmonary vein isolation be added during typical atrial flutter ablation in patients with heart failure? What do emerging data reveal about neurologic events, hemolysis, and renal safety with pulsed-field ablation?

In EP Edge® Journal Watch Issue 33, August 2026, Dr. Sharma provides a clinically focused and thought-provoking review of nine important cardiac electrophysiology studies published in Heart Rhythm and JACC: Clinical Electrophysiology.

This episode examines:

•  The proposed 8.1-month timing for oral anticoagulant discontinuation after successful AF ablation 
•  Prophylactic pulmonary vein isolation in patients with typical atrial flutter and heart failure 
•  Lesion delivery, irrigation rates, and neurovascular events with pulsed-field ablation 
•  PFA-associated hemolysis, acute kidney injury, and platform-specific renal safety 
•  Transvenous lead extraction outcomes in patients with prior sternotomy 
•  First-in-human vibration-based lead extraction 
•  The line-of-block pacing maneuver for distinguishing AV nodal from accessory pathway conduction 
•  The SCAAF-ERS electrocardiographic score for sudden cardiac arrest risk in atrial fibrillation 
•  A gain-of-function KCNJ8 variant linked with inherited and acquired J-wave syndromes 

Rather than simply listing study results, Dr. Sharma explains why each investigation was needed, what clinical uncertainty it attempted to resolve, how the methodology affects interpretation, and what the principal statistics mean in practical terms. Each paper concludes with the EP Edge Take, including the potential implications for current practice, the limitations that should temper interpretation, and the questions that future research must answer.

The episode also includes updates on the EP Edge® app, the new epedge.org website, and the upcoming EP Edge® Journal Watch collaboration with the Heart Rhythm Society.

Full references, study graphics, and the complete written analysis are available through the EP Edge® Journal Watch newsletter on LinkedIn and on Substack at epedge.substack.com.

Questions, suggestions, or concerns can be sent to [email protected].

Can anticoagulation be safely discontinued after successful atrial fibrillation ablation? Is the traditional prohibition against flecainide in structural heart disease too broad or does CAST remain an essential warning? And can AI-enabled ECGs, unipolar voltage mapping, and cardiac MRI improve how we detect AF and characterize arrhythmic substrate?

In EP Edge® Journal Watch Issue 32, Dr. Niraj Sharma examines important electrophysiology research published in Heart Rhythm and JACC: Clinical Electrophysiology, translating the methodology, statistical findings, limitations, and clinical implications into practical insights for electrophysiologists and cardiovascular clinicians.

Topics include:

• Discontinuing oral anticoagulation after AF ablation
• The clinical and economic consequences of delayed AF ablation
• Estimating AF burden after several AF-free monitoring days
• Multicenter validation of an AI-enabled ECG model for predicting AF
• Unipolar voltage mapping and lesion durability after pulsed field ablation
• High-density electroanatomic mapping versus cardiac MRI in nonischemic cardiomyopathy
• How CAST changed the direction of flecainide research
• Class Ic antiarrhythmic therapy after PCI
• Reconsidering flecainide in selected structural heart disease phenotypes
• Amiodarone-associated thyrotoxicosis in patients with pre-existing hypothyroidism

The episode separates statistical association from causal evidence and asks what these findings should and should not change in current practice. It also outlines the prospective trials needed to determine whether anticoagulation withdrawal, AI-guided AF screening, voltage-guided PFA, and phenotype-based flecainide prescribing can improve clinically meaningful outcomes.

Dr. Sharma also previews the next collaborative EP Edge® Journal Watch issue with the Heart Rhythm Society, the forthcoming EP Edge® app, and the new epedge.org platform—bringing podcasts, newsletters, EP Edge Rx, EP Edge Academy, and additional clinical and patient-focused resources into one accessible ecosystem.

References, graphics, and the complete written analysis are available through EP Edge® Journal Watch on LinkedIn and Substack:

https://epedge.substack.com

Questions, suggestions, or concerns: [email protected]

In EP Edge® Journal Watch Issue 31, August 2026, Dr. Sharma examine new evidence that challenges several familiar assumptions in cardiac electrophysiology.

Should patients with atrial fibrillation routinely stop drinking coffee? An American Heart Association scientific statement reviews the cardiovascular effects of caffeine, including randomized evidence showing a 39% lower risk of recurrent AF among habitual coffee drinkers who continued coffee after cardioversion. The discussion separates ordinary coffee consumption from energy drinks and concentrated caffeine while considering premature ventricular contractions, blood pressure, sleep, and individualized patient counseling.

The episode also investigates whether wine adds cardiovascular benefit to the Mediterranean diet. The apparent benefit weakened when moderate drinkers were compared with very-light drinkers, demonstrating how the reference group can change the statistical narrative. Importantly, these studies did not evaluate AF outcomes and do not support prescribing wine as cardiovascular therapy.

Other studies covered include:

• Pulsed-field ablation for persistent AF, with pooled one-year freedom from atrial arrhythmia of 72.3%, but no proven superiority over thermal ablation.

• Broad and predominantly left-sided pulmonary vein reconnection patterns during redo procedures after pentaspline pulsed-field ablation.

• Real-world Sphere-9 safety reports involving ventricular arrhythmias, implanted-device interactions, stroke, AV block, and other signals, interpreted in the absence of a procedural denominator.

• The SMARTBEATS randomized trial of smartphone rhythm monitoring before cardioversion, which prevented approximately one same-day cancellation for every six patients monitored.

• Autopsy-based sudden cardiac death research showing that myocardial infarction accounted for 41% of confirmed sudden cardiac deaths and highlighting the limitations of ejection fraction alone.

• End-tidal carbon dioxide trajectories during out-of-hospital cardiac arrest and why no single value should become a stand-alone termination rule.

• Atrial fibrillation, bradycardia, conduction disease, and ventricular ectopy in masters athletes, reinforcing that exceptional fitness does not provide immunity from clinically important arrhythmias.

Listen for the study rationale, methodology, clinically meaningful statistics, limitations, and the EP Edge take on how these findings may influence practice.

Complete references, graphics, and detailed analysis are available through the LinkedIn newsletter EP Edge® Journal Watch and at epedge.substack.com.

In EP Edge® Journal Watch Issue 30, July 2026, we explore the next phase of cardiac electrophysiology, from pulsed field ablation durability and physiologic pacing to neuromodulation, sleep, fitness, and lifetime arrhythmia risk.

We begin with the first-in-human VISION AF study, which evaluates an endoscope-enabled pulsed field ablation balloon that allows direct visualization of the electrode-tissue interface. Chronic invasive remapping provides a close look at pulmonary vein isolation durability and raises an important question: could seeing tissue contact become the next major advance in PFA workflow? 

Two additional studies examine practical PFA safety signals. One evaluates hemolysis-associated acute kidney injury, pulse count, chronic kidney disease, extensive left atrial ablation, and whether protocol-based hydration can reduce renal risk. Another quantifies acute blood pressure drops during circular-array PFA and identifies the first pulmonary vein treatment as the period of greatest hemodynamic vulnerability. 

The pacing and ventricular arrhythmia section includes:

•  The randomized PACE-HF trial, comparing left bundle branch area pacing with conventional right ventricular pacing 
•  A preclinical comparison of left bundle branch area antitachycardia pacing and right ventricular ATP 
•  Pulsed ultrahigh-frequency spinal cord stimulation as a potential neuromodulation strategy after myocardial infarction 

We then move beyond the EP laboratory to examine:

•  Insomnia and incident atrial fibrillation 
•  The lifetime cardiovascular tradeoff between high cardiorespiratory fitness and AF risk 
•  Whether the balance of moderate and vigorous physical activity influences cardiovascular and overall mortality 

Each paper is examined through its rationale, methodology, statistical meaning, limitations, and potential clinical consequences.

Can direct tissue visualization improve PFA durability? Should PFA pulse count be treated as a biologic dose? Is right ventricular pacing still acceptable when substantial pacing is anticipated? Could the site of antitachycardia pacing determine whether VT terminates? How should clinicians incorporate sleep and exercise into arrhythmia prevention?

This episode is intended for electrophysiologists, cardiologists, device specialists, fellows, researchers, and anyone following advances in pulsed field ablation, conduction system pacing, ventricular arrhythmia therapy, and preventive cardiology.

Read the companion newsletter and subscribe to EP Edge® Journal Watch at epedge.substack.com. 

In EP Edge® Journal Watch Issue 29, July 2026, we examine the evidence reshaping contemporary atrial fibrillation management and the rapidly changing role of catheter ablation.

Two major meta-analyses compare catheter ablation with antiarrhythmic drug therapy, addressing rhythm efficacy, serious adverse events, hospitalization, treatment intolerance, and whether medications still deserve an automatic safety advantage. We also review real-world outcomes in older adults after prior antiarrhythmic drug exposure and ask whether another medication or catheter ablation is the more appropriate next step. 

The episode then explores whether ablation can modify the natural history of AF. A CABANA analysis evaluates progression from paroxysmal to persistent AF, while new registry data challenge the assumption that asymptomatic AF represents a low-risk phenotype. The SUPPRESS-AF analysis examines whether low-voltage area ablation should be guided by the amount of abnormal atrial substrate rather than applied uniformly. 

We also discuss:

•  Urgent versus elective inpatient AF ablation 
•  Oral anticoagulation after apparently successful AF ablation 
•  The age-dependent relationship between heart failure and ischemic stroke 
•  The SLASH score for predicting AF recurrence after electrical cardioversion 

Each study is reviewed through its clinical rationale, methodology, statistical interpretation, limitations, and practical implications for electrophysiology practice.

Should catheter ablation move earlier in the AF treatment pathway? Should symptom status continue to determine access to rhythm control? When is urgent inpatient ablation justified? Does successful ablation ever eliminate the need for anticoagulation?

This episode is designed for cardiac electrophysiologists, cardiologists, fellows, researchers, and clinicians seeking a detailed, clinically relevant review of the latest atrial fibrillation evidence.

Read the companion newsletter and subscribe to EP Edge® Journal Watch at epedge.substack.com.

In this July 2026 episode of EP Edge Journal Watch, produced in collaboration with the Heart Rhythm Society (HRS), Mike Lloyd and Dr. Niraj Sharma review five studies with direct implications for contemporary cardiac electrophysiology practice.

The anchor trials are InEurHeart, a randomized comparison of computed tomography-guided versus conventional catheter ablation for post–myocardial infarction ventricular tachycardia, and OPINION, which evaluates prophylactic surgical left atrial appendage occlusion during valvular heart surgery in patients without known pre-existing atrial fibrillation. Using the workflow gains seen with pulsed field ablation in AF as context, the discussion asks whether preprocedural cardiac CT can make ischemic VT ablation more efficient while preserving the essential role of functional mapping and why future AF risk should not automatically lead to surgical LAA closure.

Rapid-fire analyses cover the relationship between alcohol consumption and incident atrial fibrillation, pulse self-examination as a simple strategy to improve AF detection, and emerging mechanistic research on caveolae, pacemaker signaling, sinus node dysfunction, and heart failure.

The episode translates randomized trials, meta-analysis, screening research, and translational science into practical implications for the EP lab, clinic, patient counseling, and shared decision-making. Essential listening for electrophysiologists, cardiologists, fellows, advanced practice clinicians, and cardiac rhythm-management teams