Episode Details

Should we add posterior wall isolation during pulsed field ablation for persistent atrial fibrillation? How durable are pulmonary vein isolation and additional atrial lines? Can a defibrillation lead placed in the left bundle branch area provide reliable early performance while simplifying device therapy?

Join Dr. Sharma for EP Edge® Journal Watch Issue 39, October 2026. We examine four papers in depth: PIFPAF-PFA, pulmonary vein isolation durability across pulsed field systems, invasive remapping of atrial lesion sets with a dual-energy lattice-tip catheter, and the LEADR LBBAP defibrillation lead study. We then give brief takeaways from twenty additional articles spanning AF ablation safety, conduction system pacing and cardiac resynchronization therapy, anticoagulation, metabolic therapies, AF progression and burden, cardioversion, cardiac arrest, ventricular arrhythmias, congenital long QT syndrome, and lead extraction.

Our aim is to connect clinically relevant findings with the methods and uncertainty behind them. We distinguish acute procedural success from chronic durability, electrical surrogates from patient outcomes, and randomized evidence from selected observational comparisons. We explain effect estimates, denominators, confidence intervals, and why a nonsignificant result does not establish equivalence. Accompanying editorials and the pacing viewpoint are integrated into the relevant discussions rather than counted as additional articles.

The newsletter contains detailed analyses of all 24 articles. The episode concentrates its extended analysis on the four featured papers below; the other twenty receive concise spoken takeaways. Article numbers retain the revised newsletter numbering, and entries follow newsletter order within each coverage section.

FOUR PAPERS COVERED IN DEPTH

1. Pulmonary Vein Isolation Using Pulsed Field Ablation With vs Without Posterior Wall Isolation in Patients With Symptomatic Persistent Atrial Fibrillation: The PIFPAF-PFA Randomized Clinical Trial

Roten L, Maurhofer J, Krisai P, et al. | JAMA | August 2026

Roten and colleagues ask whether empirical posterior wall isolation adds benefit to PFA-based PVI at first ablation for symptomatic persistent AF. In 206 randomized patients with continuous implantable-monitor surveillance, one-year Kaplan-Meier atrial tachyarrhythmia recurrence estimates were 50.6% with posterior wall isolation versus 60.6% with PVI alone. The primary result did not establish superiority: rate ratio 0.75, 95% CI 0.51–1.09, P=.13.

Mean arrhythmia burden was 6.9% versus 11.0%, and episodes lasting at least one day occurred in 10 versus 25 patients. These secondary signals require confirmation because multiple comparisons were not corrected, and most secondary endpoints were nonsignificant. Repeat intervention, drug use, and quality-of-life comparisons did not establish an advantage. We integrate Kistler and Chieng’s editorial on empirical anatomical ablation versus targeting demonstrated substrate, while avoiding cross-trial claims of superiority. Routine additional posterior wall isolation remains unproven in this setting; limited power also prevents a conclusion of equivalence.

DOI: 10.1001/jama.2026.17598

2. Durability of pulmonary vein isolation: Does the pulsed field ablation system matter?

Kakarla S, Iwakawa H, Ariyaratnam JP, et al. | Heart Rhythm | October 2026

Kakarla and colleagues compare pentaspline and balloon-in-basket PFA in a retrospective two-center cohort of 132 index procedures. Clinical recurrence was 10.5% versus 19.6% (P=.12), and 34 propensity-matched clinical pairs had six versus seven recurrences. The notable durability signal came from only 17 selected patients returning for repeat ablation: reconnection affected 9/32 versus 1/35 veins, and all veins