The Lead Podcast presented by Heart Rhythm Society

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

Join Digital Education Committee Member and podcast host Melissa E. Middeldorp, MPH, PhD, and her guests Helmut Pürerfellner, MD, FHRS, and Jonathan M. Kalman, MBBS, PhD, FHRS for this week's Lead episode. This episode was recorded LIVE at APHRS 2025 in Yokohama, Japan. The OCEAN randomized trial found that in patients who remained free of atrial arrhythmia at least one year after successful catheter ablation for atrial fibrillation, continuing anticoagulation with rivaroxaban did not significantly reduce the risk of stroke, systemic embolism, or covert cerebral infarcts compared with low-dose aspirin, with both groups experiencing very low event rates. Additionally, rivaroxaban was associated with a higher incidence of bleeding, suggesting that long-term anticoagulation may not be necessary for many post-ablation patients with low to moderate stroke risk.

Learning Objectives

• Evaluate the evidence regarding the risks and benefits of continuing oral anticoagulation after successful catheter ablation for atrial fibrillation.
• Interpret the clinical implications of low thromboembolic event rates and increased bleeding risk when comparing anticoagulation with antiplatelet therapy in post-ablation patients.
• Apply study findings to clinical decision-making by identifying which patient populations may safely discontinue long-term anticoagulation after atrial fibrillation ablation.

Article Authors

Atul Verma, M.D., David H. Birnie, M.D., Chenyang Jiang, M.D., Ph.D., Hein Heidbüchel, M.D., Gerhard Hindricks, M.D., Paulus Kirchhof, M.D., D.Sc., Jeff S. Healey, M.D. , Yunhe Wang, M.D., Nikolaos Dagres, M.D., Marc W. Deyell, M.D., Prashanthan Sanders, M.B., B.S., Ph.D., Rajeev K. Pathak, M.B., B.S., Ph.D., Pieter Koopman, M.D., Dieter Nuyens, M.D., Paul Novak, M.D., Guy Amit, M.D., Charles Dussault, M.D., Bhavanesh Makanjee, M.D., F. Russell Quinn, M.D., Umjeet Jolly, M.D., Leon Iden, M.D., Malte Kuniss, M.D., Mukul Sharma, M.D., Andrew Ha, M.D., Vidal Essebag, M.D., Ph.D., Jean Champagne, M.D., Michael D. Hill, M.D., Eric E. Smith, M.D., M.P.H., and George A. Wells, Ph.D., for the OCEAN Investigators

Host and Contributor Disclosure(s):H. Purerfellner

•Honoraria/Speaking/Teaching/Consulting: Biosense Webster, Inc., Abbott, Medtronic, Boehringer Ingelheim, Daiichi Sankyo, Bristol Meyers Squibb, Boston Scientific

J.M. Kalman

•Research: Zoll Medical Corporation, Abbott Medical, Boston Scientific •Fellowship Support: Biosense Webster, Inc., Medtronic M. Middeldorp •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 podcast host Takanori Yamaguchi, MD, PhD, and his guests Masato Fukunaga, MD, PhD and Masateru Takigawa, MD, PhD, for this week's Lead episode. This episode was recorded LIVE at APHRS 2025 in Yokohama, Japan. This episode was recorded entirely in Japanese. The OCEAN randomized trial found that in patients who remained free of atrial arrhythmia at least one year after successful catheter ablation for atrial fibrillation, continuing anticoagulation with rivaroxaban did not significantly reduce the risk of stroke, systemic embolism, or covert cerebral infarcts compared with low-dose aspirin, with both groups experiencing very low event rates. Additionally, rivaroxaban was associated with a higher incidence of bleeding, suggesting that long-term anticoagulation may not be necessary for many post-ablation patients with low to moderate stroke risk.

Learning Objectives

• Evaluate the evidence regarding the risks and benefits of continuing oral anticoagulation after successful catheter ablation for atrial fibrillation.
• Interpret the clinical implications of low thromboembolic event rates and increased bleeding risk when comparing anticoagulation with antiplatelet therapy in post-ablation patients.
• Apply study findings to clinical decision-making by identifying which patient populations may safely discontinue long-term anticoagulation after atrial fibrillation ablation.

Article Authors

Atul Verma, M.D., David H. Birnie, M.D., Chenyang Jiang, M.D., Ph.D., Hein Heidbüchel, M.D., Gerhard Hindricks, M.D., Paulus Kirchhof, M.D., D.Sc., Jeff S. Healey, M.D. , Yunhe Wang, M.D., Nikolaos Dagres, M.D., Marc W. Deyell, M.D., Prashanthan Sanders, M.B., B.S., Ph.D., Rajeev K. Pathak, M.B., B.S., Ph.D., Pieter Koopman, M.D., Dieter Nuyens, M.D., Paul Novak, M.D., Guy Amit, M.D., Charles Dussault, M.D., Bhavanesh Makanjee, M.D., F. Russell Quinn, M.D., Umjeet Jolly, M.D., Leon Iden, M.D., Malte Kuniss, M.D., Mukul Sharma, M.D., Andrew Ha, M.D., Vidal Essebag, M.D., Ph.D., Jean Champagne, M.D., Michael D. Hill, M.D., Eric E. Smith, M.D., M.P.H., and George A. Wells, Ph.D., for the OCEAN Investigators

Host and Contributor Disclosure(s):

T. Yamaguchi

•Honoraria/Speaking/Teaching/Consulting: Abbott Japan, Japan Medtronic, Inc., Daiichi Sankyo, Boehringer Ingelheim, Bayer Healthcare Pharmaceutical, Japan, Nihon Kohden, Japan Lifeline, Novartis

M. Takigawa

•Honoraria/Speaking/Teaching/Consulting: Biosense Webster, Inc., Medtronic Japan, Abbott Japan •Research: Abbott, Biosense Webster, Inc., Medtronic, Inc. M. Fukunaga •Honoraria/Speaking/Teaching/Consulting: Boston Scientific Japan, 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 Melissa E. Middeldorp, MPH, PhD, and her guests Eue-Keun Choi, MD, PhD, and Sandeep Prabhu, MBBS, PhD for this week's Lead episode. This episode was recorded LIVE at APHRS 2025 in Yokohama, Japan. The DECAF trial investigated whether continuing regular caffeinated coffee consumption versus complete abstinence affected the recurrence of atrial fibrillation (AF) or atrial flutter in patients after successful cardioversion. Over six months in this randomized study of 200 adults, those who drank at least one cup of caffeinated coffee daily had a significantly lower rate of AF or flutter recurrence compared to those who abstained (47% vs. 64%), suggesting moderate coffee intake may be safe and potentially beneficial for rhythm stability in this setting.

Learning Objectives

• Evaluate the impact of caffeinated coffee consumption versus abstinence on atrial fibrillation recurrence following cardioversion.

• Interpret the design and key outcomes of the DECAF randomized clinical trial and their relevance to clinical practice.

• Apply the trial findings to patient counseling regarding caffeine intake and atrial fibrillation management.

Article Authors

Christopher X. Wong, MBBS, MPH, PhD; Christopher C. Cheung, MD, MPH; Gabrielle Montenegro, BA, Hannah H. Oo, BS; Isabella J. Peña, BA; Janet J. Tang, MPH, PhD; Samuel J. Tu, MBBS; Grace Wall, BA1; Thomas A. Dewland, MD; Joshua D. Moss, MD; Edward P. Gerstenfeld, MD; Zian H. Tseng, MD, MAS; Henry H. Hsia, MD; Randall J. Lee, MD, PhD; Jeffrey E. Olgin, MD; Vasanth Vedantham, MD; Melvin M. Scheinman, MD; Catherine Lee, PhD; Prashanthan Sanders, MBBS, PhD; Gregory M. Marcus, MD, MAS

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD

Eue-Keun Choi, MD, PhD

Sandeep Prabhu, MBBS, PhD

Link to article

Host and Contributor Disclosure(s):

E.K. Choi

•Honoraria/Speaking/Teaching/Consulting: Daiichi •Stock Options, Privately Held: DeepQure •Research: Biosense Webster, Inc., Bristol-Meyers Squibb, Bayer Healthcare Pharmaceuticals, Chong Kun Dang Pharmaceutical Corp., Jeil Pharmaceutical Co, Medtronic, Inc., Samjinpharm, Seers Technology, Skylabs, Genome Opinion Inc

S. Prabhu

•Honoraria/Speaking/Consulting: Biosense Webster •Research: National Health and Medical Research •Fellowship Support: St. Jude Medical Center, Boston Scientific

M. Middeldorp •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 podcast host Takanori Yamaguchi, MD, PhD, and his guests Koichi Magashina, MD, PhD, and Michifumi Tokuda, MD, PhD for this week's Lead episode. This episode was recorded LIVE at APHRS 2025 in Yokohama, Japan. This episode is recorded entirely in Japanese. The DECAF trial investigated whether continuing regular caffeinated coffee consumption versus complete abstinence affected the recurrence of atrial fibrillation (AF) or atrial flutter in patients after successful cardioversion. Over six months in this randomized study of 200 adults, those who drank at least one cup of caffeinated coffee daily had a significantly lower rate of AF or flutter recurrence compared to those who abstained (47% vs. 64%), suggesting moderate coffee intake may be safe and potentially beneficial for rhythm stability in this setting.

Learning Objectives

• Evaluate the impact of caffeinated coffee consumption versus abstinence on atrial fibrillation recurrence following cardioversion.

• Interpret the design and key outcomes of the DECAF randomized clinical trial and their relevance to clinical practice.

• Apply the trial findings to patient counseling regarding caffeine intake and atrial fibrillation management.

Article Authors

Christopher X. Wong, MBBS, MPH, PhD; Christopher C. Cheung, MD, MPH; Gabrielle Montenegro, BA, Hannah H. Oo, BS; Isabella J. Peña, BA; Janet J. Tang, MPH, PhD; Samuel J. Tu, MBBS; Grace Wall, BA1; Thomas A. Dewland, MD; Joshua D. Moss, MD; Edward P. Gerstenfeld, MD; Zian H. Tseng, MD, MAS; Henry H. Hsia, MD; Randall J. Lee, MD, PhD; Jeffrey E. Olgin, MD; Vasanth Vedantham, MD; Melvin M. Scheinman, MD; Catherine Lee, PhD; Prashanthan Sanders, MBBS, PhD; Gregory M. Marcus, MD, MAS

Podcast Contributors

Takanori Yamaguchi, MD, PhD Koichi Magashina, MD, PhD Michifumi Tokuda, MD, PhD

Link to article

Host and Contributor Disclosure(s):

T. Yamaguchi

• Honoraria/Speaking/Teaching/Consulting: Abbott Japan, Japan Medtronic, Inc., Daiichi Sankyo, Boehringer Ingelheim, Bayer Healthcare Pharmaceutical, Japan, Nihon Kohden, Japan Lifeline, Novartis

K. Nagashina

Nothing to disclose

M. Tokuda

• Honoraria/Speaking/Consulting: Medtronic Japan

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 (Kauvery Hospital), and his guests Nitish Badhwar, MBBS, FHRS (Stanford University), and Yash Lokhandwala, MD, DM, FACC (Holy Family Hospital) for this week's Lead episode. This state-of-the-art review synthesizes current knowledge on multifocal ectopic Purkinje-related premature contractions (MEPPC) syndrome, highlighting its genetic underpinnings, distinctive electrophysiologic features, and clinical presentation across age groups. The authors emphasize advances in diagnosis and management, including the role of targeted pharmacologic therapy and catheter ablation, while identifying ongoing gaps in evidence and priorities for future research in this rare but increasingly recognized arrhythmia syndrome.

Learning Objectives

• Describe the genetic, clinical, and electrophysiologic characteristics of MEPPC syndrome and how they distinguish it from other causes of frequent ventricular ectopy.

• Discuss current diagnostic and management strategies for MEPPC syndrome, including the roles of pharmacologic therapy and catheter ablation.

• Identify key knowledge gaps and future research directions highlighted in the review and their implications for clinical practice.

Article AuthorsPaolo Basile, MD, Maria Cristina Carella, MD, Stefania Zaccaro, MD, Marco Maria Dicorato, MD, Luca Sgarra, MD, Yamna Khan, MD, Gianluca Pontone, MD, PhD, Giovanni Luzzi, MD, PhD, Vincenzo Ezio Santobuono, MD, PhD, Cinzia Forleo, MD, PhD, Marco Matteo Ciccone, MD, PhD, and Andrea Igoren Guaricci, MD, PhD

Podcast Contributors Nitish Badhwar, MBBS, FHRS Yash Lokhandwala, MD, DM, FACC Deep Chandh Raja, MBBS, MD, PhD

Host and Contributor Disclosure(s): N. Badhward•Speaking/Teaching/Consulting: Abbott, Zoll Medical Corporation Y. Lokhandwala•Speaking/Teaching/Consulting/Authoring: Indian Pacing and Electrophysiology Journal

D.C. Raja •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 Tina Baykaner, MD, MPH, HRS Digital Education Committee Vice-Chair, and her guests Mikhael F. El-Chami, MD, FHRS and Devi G. Nair, MD, FHRS for this week's Lead episode. This article summarizes the worldwide experience retrieving chronically implanted active helix-fixation leadless ventricular pacemakers (the Aveir/Abbott platform) across regulatory clinical trials. The authors assess real-world feasibility, procedural techniques, success rates, and complications of retrieval after long dwell times, demonstrating that devices can be removed safely and effectively even years after implant—up to about 9 years in follow-up. Overall, chronic retrieval success remained high with a low rate of serious adverse events, supporting helix-fixation leadless systems as a manageable long-term pacing strategy when replacement or removal is needed.

Learning Objectives

• Explain the clinical indications for chronic retrieval of helix-fixation leadless pacemakers and how these differ from tine-fixation platforms.

• Summarize the reported worldwide chronic retrieval success rates, implant-duration range, and key procedural or anatomic reasons for retrieval failure.

• Identify practical procedural considerations (e.g., docking-button access, retrieval catheter use, imaging support) that improve the likelihood of safe long-term leadless pacemaker removal.

Article for Discussion: Worldwide Chronic Retrieval Experience of the Helix Fixation Leadless Cardiac Paccemaker

Article Authors and Podcast Contributors

Article Authors

Derek V. Exner, Reinoud E. Knops, Daniel J. Cantillon, Pascal Defaye, Rajesh Banker, Paul Friedman, Chris Hubbard, Stephanie M. Delgado, Anuradha Bulusu, and Vivek Y. Reddy

Podcast Contributors

Tina Baykaner, MD, MPH

Mikhael F. El-Chami, MD, FHRS

Devi G. Nair, MD, FHRS

Faculty Disclosures

Host Disclosure(s):

T. Baykaner

•Honoraria/Speaking/Consulting: Volta Medical, Medtronic, Pacemate, Johnson and Johnson, Abbot Medical, Boston Scientific •Research: NIH ​Contributor Disclosure(s):

M. El-Chami

•Research: Medtronic, Boston Scientific •Speaking/Teaching/Consulting: Medtronic, Boston Scientific

D. Nair

•Speaking/Teaching/Consulting: Sieman's Healthineers •Membership on Advisory Committees: Biosense Webster, Medtronic, Abbott Medical, Boston Scientific

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 Phillip Cuculich, MD and his guests Tina Baykaner, MD, MPH and Atul Verma, MD, FHRS for this lively discussion of a cutting edge topic. The ALONE-AF trial evaluated whether patients who remained free of atrial fibrillation for at least one year after catheter ablation could safely discontinue long-term oral anticoagulation. In this randomized study of more than 800 patients, stopping anticoagulation resulted in similarly low rates of stroke or systemic embolism and significantly fewer major bleeding events compared with continuing therapy. The findings suggest that, in carefully selected post-ablation patients, long-term anticoagulation discontinuation may be a safe and beneficial strategy.

Learning Objectives

• Evaluate the methodology and patient selection criteria of the ALONE-AF randomized trial to understand which post-ablation patients may be appropriate candidates for long-term anticoagulation discontinuation.
• Interpret the trial's primary and secondary outcomes to assess the comparative risks of thromboembolism and major bleeding in patients who discontinue versus continue oral anticoagulation after successful AF ablation.
• Discuss the clinical implications of ALONE-AF for shared decision-making, guideline considerations, and the development of individualized anticoagulation strategies following catheter ablation.

Article Authors

Daehoon Kim, MD; Jaemin Shim, MD; Eue-Keun Choi, MD, Il-Young Oh, MD; Jun Kim, MD; Young Soo Lee, MD; Junbeom Park, MD; Jum-Suk Ko, MD; Kyoung-Min Park, MD; Jung-Hoon Sung, MD; Hyung Wook Park, MD; Hyung-Seob Park, MD; Jong-Youn Kim, MD, Ki-Woon Kang, MD; Dongmin Kim, MD; Jin-Kyu Park, MD; Dae-Hyeok Kim, MD; Jin-Bae Kim, MD; Hee Tae Yu, MD; Tae-Hoon Kim, MD; Jae-Sun Uhm, MD; Hui-Nam Pak, MD1; Boyoung Joung, MD; for the ALONE-AF Investigators

Podcast Contributors

Tina Baykaner, MD, MPH Phillip Cuculich, MD Atul Verma, MD, FHRS

Article for Discussion

Join host and HRS Digital Education Committee Member Melissa Middeldorp, MPH, PhD and her guests Rod Passman, MD, FHRS, and Emma Svenberg, MD, PhD, live at HRX 2025. In this episode, we explore the AMALFI Randomized Clinical Trial, which evaluated whether remote, wearable-based screening can effectively detect asymptomatic atrial fibrillation in high-risk adults. The discussion breaks down the study design, key findings, and implications for population-level AF screening strategies. It also examines how emerging digital health tools may integrate into routine cardiovascular prevention.

Learning Objectives

• Describe the design, patient population, and primary outcomes of the AMALFI Randomized Clinical Trial.

• Evaluate the effectiveness of remote wearable monitoring compared with usual care for detecting asymptomatic atrial fibrillation.

• Discuss the potential clinical and health-system implications of implementing large-scale remote AF screening in high-risk populations.

Article Authors

Rohan Wijesurendra, DPhil, Guilherme Pessoa-Amorim, DPhil, Georgina Buck, MSc,Charlie Harper, DPhil, Richard Bulbulia, MD, Alison Offer, PhD, Nicholas R. Jones, DPhil, Christine A'Court, MA, Rijo Kurien, MSc, Karen Taylor, MSc, Barbara Casadei, DPhil, Louise Bowman, MD.

Podcast Contributors

Melissa E. Middeldorp, MPH, PhD

Rod S. Passman, MD, FHRS

Emma Svennberg, MD, PhD

Article for Discussion

Join host and Digital Education Committee Member Sandeep A Saha, MD, MS, FHRS for this lively discussion with his colleagues Charles A. Henrikson, MD, MPH, FHRS and Arun R. Mahankali Sridhar, MBBS, MPH, FACC. About this Article: In patients with symptomatic premature ventricular complexes (PVCs) refractory to medical therapy, non-invasive low-level tragus stimulation of the auricular branch of the vagus nerve significantly reduced median PVC burden compared to sham stimulation (median reduction ~13.4% vs ~8.6%; P = 0.021). The findings suggest that autonomic neuromodulation via transcutaneous vagal stimulation may offer a novel adjunctive therapy for frequent PVCs, although further larger trials are needed to evaluate long-term outcomes.

Learning Objectives

• Describe the rationale and mechanism by which transcutaneous vagus nerve stimulation (tVNS) may modulate autonomic tone and reduce premature ventricular contractions.
• Summarize the design, methods, and key outcomes of the NoVa-PVC randomized crossover trial evaluating tVNS for symptomatic PVC reduction.
• Evaluate the clinical implications, limitations, and potential future applications of noninvasive neuromodulation as a therapeutic approach for ventricular arrhythmias.

Article Authors Stefanos Zafeiropoulos MD, MBA, Kristie Coleman MPH, RN, Jonathan Kogan,Dimitrios Varrias MD, Jonas Leavitt BS, Alexandra Bekiaridou MD, Theodoros Zanos PhD, Stavros Zanos PhD, MD, Stavros Stavrakis PhD, MD, Stavros Mountantonakis MD, MBA Podcast Contributors Sandeep A Saha, MD, MS, FHRS Charles A. Henrikson, MD, MPH, FHRS Arun R. Mahankali Sridhar, MBBS, MPH, FACC

All relevant financial relationships have been mitigated. Host Disclosure(s): S. Saha

•Speaking/Teaching/Consulting: Medtronic

​Contributor Disclosure(s): C. Henrikson

•Honoraria/Speaking/Teaching/Consulting: American College of Cardiology

A. Sridhar

•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.