The Lead Podcast presented by Heart Rhythm Society

Join an expert-led discussion exploring the safety and clinical outcomes of Class 1c antiarrhythmic therapy following percutaneous coronary intervention (PCI) in patients with new-onset atrial fibrillation, based on insights from a nationwide cohort study. Deep Chandh Raja, MBBS, MD, PhD (Australian National University and Kauvery Hospital) hosts a dynamic conversation with Sandeep Gautam, MD, MPH, FHRS (University of Missouri Health) and Deepak Padmanabhan, MD, FHRS (Narayana Institute of Cardiac Sciences, Bengaluru).

Together, they examine real-world data on the use of Class 1c agents in a traditionally high-risk population, addressing long-standing concerns about proarrhythmia and ischemic heart disease. The discussion will highlight patient selection, evolving clinical practice patterns, and implications for guideline-directed management, offering clinicians practical insights into optimizing rhythm control strategies in complex post-PCI patients.

Learning Objectives

• Evaluate the safety profile and clinical outcomes associated with Class 1c antiarrhythmic therapy in patients with new-onset atrial fibrillation following PCI.
• Identify appropriate patient selection criteria and clinical considerations when prescribing Class 1c agents in the context of ischemic heart disease.
• Apply evidence from nationwide cohort data to inform decision-making and optimize rhythm management strategies in post-PCI atrial fibrillation patients.

Link to the Article for Discussion

Article AuthorsTing-Chun Huang MD, Po-Hsueh Su MD, Hui-Wen Lin MS, Po-Tseng Lee MD, Yu Liao MD, Chao-Yu Chen MD, Li-Hao Yap MD, Sheng-Hsiang Lin PhD, Yi-Heng Li MD, PhD

Podcast ContributorsDeep Chandh Raja, MBBS, MD, PhD Sandeep Gautam, MD, MPH, FHRS Deepak Padmanabhan, MD, FHRS

Host and Contributor Disclosure(s):

D.C. RajaNothing to disclose.

S. Gautam Honoraria/Teaching/Speaking/Consulting: Biosense Webster Fellowship Support: Medtronic Inc., Abbott

D. Padmanabhan Nothing to disclose.

Join Digital Education Committee member and podcast host Melissa E. Middeldorp, MPH, PhD, along with this week's guest contributors,Sheldon Litwin, MD from the Medical University of South Carolina and Abhishek Deshmuckh, MBBS from the Mayo Clinic for this week's episode.

This real-world retrospective cohort study evaluated whether glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy is associated with improved outcomes after atrial fibrillation (AF) ablation in obese patients using a large multicenter electronic health record database (TriNetX). After propensity matching 6,700 patients (3,350 GLP-1RA users and 3,350 non-users), GLP-1RA therapy was associated with significantly lower AF recurrence, progression to permanent AF, cardiovascular and heart failure hospitalizations, and all-cause mortality over a median ~2-year follow-up, although repeat ablation rates were unchanged. The authors propose that benefits may be mediated through weight-loss, reduction in systemic inflammation and epicardial fat, improved metabolic control, and potential direct atrial effects, but emphasize that causal inference is limited due to observational design and lack of weight-loss trajectory or adherence data. Overall, the study suggests GLP-1RAs could become an adjunct rhythm-control strategy in obese AF patients undergoing ablation, warranting prospective randomized trials.

Learning Objectives

• Understand the association between GLP-1 RA therapy and reduced AF recurrence and cardiovascular outcomes after catheter ablation in obese patients.
• Evaluate the potential mechanisms and clinical implications of GLP-1 RAs as an adjunctive metabolic therapy in rhythm control strategies for AF.

Article for Discussion

Article Authors

Sandrine Venier, Pascal Defaye, Lisa Lochon, Rémi Benali, Arnaud Bisson, Adrien Carabelli, Youssou Diouf, Peggy Jacon, Laurent Fauchier

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD Abhishek Deshmuckh, MBBS Sheldon Litwin, MD

Host and Contributor Disclosure(s): M. Middeldorp

Nothing to disclose. A. Deshmukh •Honoraria/Teaching/Speaking/Consulting: GE Healthcare S. Litwin

• Honoraria/Teaching/Speaking/Consulting: Axon Therapies, Novo Nordisk, Alleviant, Corvia Medical

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee member and podcast host Melissa E. Middeldorp, MPH, PhD, along with this week's guest contributors, Joshua Silverstein MD, FHRS from Allegheny Health Network and Jonathan Ariyaratnam, BChir, MA, MB, CCDS, CEPS-A from the University of Adelaidefor this week's episode.

This study by Vad and colleagues examined markers of atrial cardiomyopathy (AtCM) in 26,467 UK Biobank participants without prior atrial fibrillation (AF), heart failure (HF), or stroke, integrating cardiac MRI, ECG, clinical risk factors, and genetic data. AtCM was defined using four markers: left atrial dilation, reduced left atrial emptying fraction (120 ms), and abnormal P-wave terminal force and 15.7% of individuals had at least one marker, while 2.3% had two or more. Over a median follow-up of nearly five years, the presence of AtCM markers showed a dose–response relationship with incident AF, with a HR: 4.59 in those with ≥2 markers and was also strongly associated with HF and ischemic stroke. Adding AtCM markers to clinical and genetic risk models improved AF risk prediction, supporting the concept that atrial cardiomyopathy may represent a common substrate linking AF, HF, and stroke and may help refine future risk stratification strategies.

Article for Discussion

Learning Objectives

• Understand how imaging- and ECG-based markers of atrial cardiomyopathy are defined and how they relate to the risk of incident AF, heart failure, and stroke.
• Evaluate how integrating atrial cardiomyopathy markers with clinical and genetic risk scores may improve risk stratification for AF and related cardiovascular outcomes.

Article Authors

Oliver B Vad, Nick van Vreeswijk, Ahmed S Yassin, Yuri Blaauw, Christian Paludan-Müller, Jørgen K Kanters, Claus Graff, Ulrich Schotten, Emelia J Benjamin, Jesper H Svendsen, Michiel Rienstra

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD Joshua R. Silverstein, MD, FHRS Jonathan Ariyaratnam, BChir, MA, MB, CCDS, CEPS-A

Host and Contributor Disclosure(s):

M. Middeldorp

Nothing to disclose. J. Ariyaratnam Nothing to disclose.

J. Silverstein

• Honoraria/Speaking/Consulting: Medical Device Business Services, Biosense Webster, Inc., Medtronic
• Stocks, Privately Held: Heart Rhythm Clinical Solutions/3PH Alliance

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee member and podcast host Melissa E. Middeldorp, MPH, PhD, along with this week's guest contributors, Nino Isakadze, MD, MHS, and Geraldine A. Lee, PhD, FESC for this week's episode. The POP-AF trial was a prospective, randomized controlled study evaluating whether a nurse-led, integrated lifestyle intervention before AF ablation improves outcomes. A total of 145 patients with symptomatic paroxysmal or persistent AF and at least one modifiable risk factor were randomized to either standard pre-ablation care or a structured, multidisciplinary lifestyle program targeting weight loss, physical activity, alcohol reduction, smoking cessation, blood pressure, lipid and glycemic control, and obstructive sleep apnea treatment. After pulsed-field pulmonary vein isolation, patients were followed for 12 months. The primary endpoint, a composite of repeat ablations and cardioversions was reduced by 51% in the intervention group (IRR 0.49, 95% CI 0.30–0.78). Successful index ablation without antiarrhythmic drugs was also significantly higher (76% vs 53%). Notably, these benefits were achieved with an average weight loss (~5.5%), suggesting that comprehensive, personalized risk-factor management meaningfully enhances rhythm control outcomes when implemented before ablation.

Read the Article

Learning Objectives

• Understand how a structured, nurse-led integrated lifestyle intervention before AF ablation significantly reduces repeat procedures and cardioversions compared with standard care.
• Evaluate the role of comprehensive risk-factor modification which includes weight, blood pressure, alcohol use, and OSA management improves rhythm control outcomes in patients undergoing PVI.

Article Authors

Jasper Vermeer, Tineke Vinck-de Greef, Maarten van den Broek, Bianca de Louw, Gijs van Steenbergen, Dennis van Veghel, Lukas Dekker

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD Nino Isakadze, MD, MHS Geraldine A. Lee, PhD, FESC

All relevant financial relationships have been mitigated. Host and Contributor Disclosure(s):

M. Middeldorp

Nothing to disclose.

N. Isakadze

• Research: Apple, Inc., Itamar Medical
• Board Membership: Boston Scientific

G. Lee

• Research: H2020 (EHRA-PATHS)

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee member and podcast host Deep Chandh Raja, MBBS, MD, PhD, along with this week's guest contributors, Senthil Thambidorai, MD, FHRS and Lee Karl Thien, MD, CCDS for this week's episode. This real-world registry study evaluated the safety, feasibility, and mid-term outcomes of pulsed field ablation (PFA) for cavotricuspid isthmus (CTI)–dependent atrial flutter. Acute bidirectional CTI block was achieved in nearly all patients, with a low complication rate and high freedom from recurrent flutter at mid-term follow-up. The findings suggest that PFA is an effective non-thermal alternative for typical atrial flutter ablation, though long-term durability and comparisons with conventional thermal energy sources require further investigation.

Learning Objectives

• Describe the procedural success rates and safety profile of pulsed field ablation for CTI-dependent atrial flutter.
• Compare pulsed field ablation with traditional thermal ablation strategies for typical atrial flutter.
• Discuss the role of emerging ablation technologies in the management of supraventricular tachyarrhythmias.

Article AuthorsJuan F. Rodriguez-Riascos, MD, Hema S. Vemulapalli, MBBS, Poojan Prajapati, MBBS, Padmapriya Muthu, MBBS, James Y. Kim, MD, Dan Sorajja, MD, Win-Kuang Shen, MD, Hicham El Masry, MD, Mayank Sardana, MBBS, MD, Arturo M. Valverde, MD, Thomas M. Munger, MD, and Komandoor Srivathsan, MD

Podcast ContributorsSenthil Thambidorai, MD, FHRS Lee Karl Thien, MD, CCDS Deep Chandh Raja, MBBS, MD, PhD

All relevant financial relationships have been mitigated. Host and Contributor Disclosure(s):

D. Raja Nothing to disclose.

S. Thambidorai Nothing to disclose.

L. K. Thien Nothing to disclose.

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Vice-Chair and podcast host Tina Baykaner, MD, MPH, along with this week's guest contributors, Jackson J. Liang, DO and Edward P. Gerstenfeld, MD, MS, FHRS for this week's episode. This study evaluates the relationship between hospital ventricular tachycardia (VT) ablation volume and post-procedural complications, examining whether institutional procedural experience influences patient outcomes. The authors analyze complication rates across centers with varying VT ablation volumes to assess potential volume–outcome associations. Findings from this work provide important insights into procedural risk, quality metrics, and the potential impact of case volume on VT ablation safety.

Learning Objectives

• Describe the relationship between hospital VT ablation procedural volume and post-procedural complication rates.
• Identify patient, procedural, and institutional factors that may contribute to complications following ventricular tachycardia ablation.
• Discuss how volume–outcome findings can inform quality improvement initiatives, referral patterns, and procedural planning for VT ablation programs.

Article Authors

Agam Bansal, Anirudh Nandan, Jakub Sroubek, Justin Lee, Koji Higuchi, Ayman Hussein, Shady Nakhla, Mina Chung, Niraj Varma, Walid Saliba, Mandeep Bhargava, Tyler Taigen, Mohamed Kanj, Oussama Wazni, and Pasquale Santangeli

Podcast Contributors

Tina Baykaner, MD, MPH Jackson J. Liang, DO Edward P. Gerstenfeld, MD, MS, FHRS

All relevant financial relationships have been mitigated. Host and Contributor Disclosure(s):

T. Baykaner•Honoraria/Speaking/Consulting: Volta Medical, Medtronic, Pacemate, Johnson and Johnson, Abbot Medical, Boston Scientific •Research: NIH

E. Gerstenfeld •Speaking/Teaching/Consulting: Medtronic, Adiago Medical, Biosense Webster, Inc., Abbott, Boston Scientific, Abbott Medical, Varian Medical Systems •Research: Boston Scientific, Abbott Medical •Board Membership: American College of Cardiology Foundation J. Liang •Speaking/Teaching/Consulting: Biotronik, Abbott, Bionsense Webster, Inc.

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Member and podcast host Jason T. Jacobson, MD, FHRS, along with this week's guest contributors, Gaurav A. Upadhyay, MD, FHRS and Pugazhendhi Vijayaraman, MD, FHRS for this exciting conversation! This Heart Rhythm Journal article explores the electrophysiologic signatures that occur during left bundle branch pacing (LBBP) as lead position changes, with a focus on identifying "uninterrupted transition" patterns in recorded electrograms. The findings help clarify how subtle lead movement within the interventricular septum can alter electrogram morphology and capture behavior, improving clinicians' ability to confirm true conduction system engagement during implantation.

Read the article

Learning Objectives

• Describe the electrophysiologic basis of lead position–dependent electrogram changes observed during left bundle branch pacing.
• Differentiate uninterrupted transition electrogram patterns from other pacing capture transitions (e.g., septal capture vs LBB capture).
• Apply electrogram transition findings to improve procedural decision-making for confirming optimal lead placement during LBBP implantation.

Article AuthorsJiabo Shen, MD, Longfu Jiang, MD, Hao Wu, MD, Lu Zhang, MD, Hengdong Li, MD, Lifang Pan, MD

Podcast ContributorsGaurav A. Upadhyay, MD, FHRS Pugazhendhi Vijayaraman, MD, FHRS Jason T. Jacobson, MD, FHRS

Host and Contributor Disclosure(s):

J. Jacobson

• Honoraria/Speaking/Teaching/Consulting: Zoll Medical Corporation, Vektor Medical Inc.
• Stocks, Privately Held: Atlas 5D
• Research: CardioFocus, Inc.
• Membership on Advisory Committees: Abbott Medical, Johnson and Johnson

G. Upadhyay

• Honoraria/Speaking/Teaching/Consulting: Boston Scientific, Abbott, Medtronic, Biontronik, Zoll Medical Corporation

P. Vijayaraman

• Honoraria/Speaking/Consulting: Medtronic, Boston Scientific, Biotronik, Abbott Medical, Abbott
• Research: Medtronic
• Fellowship Support: Medtronic

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Welcome to this week's episode of The Lead. Join HRS Digital Education Committee member and podcast host Danesh Kella, MBBS, FHRS as he welcomes his guests Rahul N Doshi, MD, FHRS and Robert D Schaller, DO, FHRS. They are discussing Mechanical Vacuum Aspiration and Debulking of Large Vegetations During Cardiac Implantable Electronic Device Extractions, which was published in the Journal of the American College of Cardiology in October 2025. This article describes the use of mechanical vacuum aspiration systems to debulk large intracardiac vegetations during cardiac implantable electronic device (CIED) extraction, aiming to reduce embolic risk and procedural complications. The authors highlight procedural techniques, patient selection, and safety considerations when combining aspiration with transvenous lead extraction. This approach represents an important adjunctive strategy for managing complex CIED infections with large vegetations.

Learning Objectives

• Describe the role of mechanical vacuum aspiration in the management of large vegetations during CIED extraction procedures.
• Identify patient selection criteria and procedural considerations for safely combining vegetation debulking with transvenous lead extraction.
• Recognize potential risks, benefits, and complications associated with aspiration-assisted extraction in patients with CIED infection.

Article for Discussion: https://www.jacc.org/doi/10.1016/j.jacc.2025.07.043

Article Authors

Yury Malyshev, Marc A. Miller, Anelechi Anyanwu, George C. Shaw, Mouhannad Sadek, Seth Newman, Sakshum Chadha, Maryam Saleem, Nana Gegechkori, Abhishek Maan, Daniel Musikantow, Mohit Turagam, William Whang, Joshua Lampert, Jacob Koruth, Srinivas Dukkipati, Eric Neibart, and Vivek Y. Reddy

Podcast Contributors

Danesh Kella, MBBS, FHRS Rahul N Doshi, MD, FHRS Robert D Schaller, DO, FHRS

Host and Contributor Disclosure(s):

D. Kella

• Honoraria/Speaking/Teaching/Consulting: Zoll Medical Corporation, MBW Spectrum

R. Doshi

• Honoraria/Speaking/Teaching/Consulting: Boston Scientific, Kestra, Inc., Abbott, Impulse Dynamics

R. Schaller

• Honoraria/Speaking/Consulting: Medtronic, Boston Scientific, Philips, Cook Medical
• Research: Abbott Medical

Staff Disclosure(s) (note: HRS staff are NOT in control of educational content. Disclosures are provided solely for full transparency to the learner):

S. Sailor: No relevant financial relationships with ineligible companies to disclose.

Join Digital Education Committee Member and podcast host Deep Chandh Raja, MBBS, MD, PhD , and his guests Georgios Leventopoulos, MD, and Muthiah Subramanian, MD, CCDS, CEPS-A, for this week's Lead episode. This Heart Rhythm article investigates the Bachmann bundle as a target for pacing by using retrograde electrical mapping and correlating findings with underlying myocardial microstructure. The piece provides detailed insights into how Bachmann bundle activation pathways relate to tissue architecture, with implications for optimizing physiologic pacing strategies. These findings may help refine pacing techniques that aim to better mimic natural conduction and improve clinical responses.

Learning Objectives

• Describe the anatomical and electrophysiologic characteristics of the Bachmann bundle and its role in atrial conduction.
• Explain how retrograde mapping and microstructural correlation can identify optimal pacing targets within the atrial conduction system.
• Evaluate the potential clinical implications of Bachmann bundle pacing for achieving more physiologic atrial activation.

Article AuthorsDaniel L. Lustgarten, MD, PhD, FHRS, Nicole Habel, MD, PhD, Margaret Infeld, MD, MS, Daniel Correa de Sa, MD, Robert Lobel, MD, Peter Spector, MD, FHRS, Nathaniel Thompson, MD, Joseph Winget, MD, Neal Duong, BME, Bo Ye, MD, PhD, Paul A. Iaizzo, PhD, Markus Meyer, MD, PhD

Podcast Contributors Deep Chandh Raja, MBBS, MD, PhD

Georgios Leventopoulos, MD

Muthiah Subramanian, MD, CCDS, CEPS-A

Article Being Discussed

Host and Contributor Disclosure(s):

G. Leventopolous

• Nothing to disclose.

D.C. Raja

• Nothing to disclose.

M. Subramanian •Nothing to disclose.

Join Digital Education Committee Chair and podcast host Michael S. Lloyd, MD, FHRS, and his guests Kelvin C. Chua, MBBS, MD, FHRS, CEPS-A, and Rahul N Doshi, MD, FHRS, for this week's Lead episode, which was recorded live at APHRS 2025 in Kyoto, Japan. This discussion will review recent evidence on the feasibility and safety of pulsed field ablation (PFA) for coronary sinus and left atrial appendage isolation, as well as mitral isthmus ablation, focusing on both acute and chronic outcomes. Panelists will examine procedural considerations, lesion durability, and safety signals highlighted in the study, and explore how these findings may inform evolving ablation strategies for complex atrial arrhythmias.

Learning Objectives

• Summarize the acute and chronic feasibility and safety outcomes of pulsed field ablation (PFA) for coronary sinus isolation, left atrial appendage isolation, and mitral isthmus ablation as reported in the study.

• Evaluate procedural techniques and lesion durability considerations associated with using PFA in anatomically complex atrial structures.

• Assess the potential clinical implications of these findings for incorporating PFA into ablation strategies for complex atrial arrhythmias, including patient selection and risk mitigation.

Podcast Contributors

Michael S. Lloyd, MD, FHRS Kelvin C. Chua, MBBS, MD, FHRS, CEPS-A Rahul N Doshi, MD, FHRS

Host and Contributor Disclosure(s):

K.C. Chua•Nothing to disclose. R. N. Doshi•Speaking/Teaching/Consulting/Authoring: Boston Scientific, Kestra Inc., Abbott, Impulse Dynamics USA

M. S. Lloyd •Honoraria/Speaking/Consulting: Medtronic, Agra MedTech, Circa Scientific •Membership on Advisory Committees: Boston Scientific Article for Discussion