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 Authors

Paolo 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

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

M. El-Chami

D. Nair

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

​Contributor Disclosure(s):

C. Henrikson

A. Sridhar

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.

Description

Join host and HRS Digital Education Committee Chair Michael S. Lloyd, MD, FHRS and his guests Miguel A. Leal, MD, FHRS, and Jason T. Jacobson, MD, FHRS, live at HRX 2025.

In this prospective series of 12 device-naïve patients (median LVEF ~30%), the authors attempted permanent implantation of a single-coil DF-4 ICD lead into the left bundle branch area (LBBA). They achieved successful implantation with adequate sensing and pacing in 75% of patients, and during short-term follow-up the lead and RV parameters remained stable; minor complications occurred in ~25% of patients (lead micro-dislodgment and septal perforations). The authors conclude that LBBA ICD lead implantation is feasible with current tools and acceptable short-term outcomes, but note the higher-than-expected minor complication rate and emphasize the need for dedicated toolkits, higher operator volume, and a procedural learning curve.

Learning Objectives

• Describe the procedural feasibility, safety considerations, and short-term outcomes associated with left bundle branch area (LBBA) DF-4 defibrillator lead implantation.
• Identify key technical caveats and patient selection factors relevant to adopting this emerging pacing strategy in clinical practice.

Article Information

Permanent Left Budnle Branch Area DF-4 Debibrillator Lead Implantation Feasibility, Procedural Caveats, Safety, and Follow-Up

Article Authors

Anindya Ghosh, Chenni S. Sriram, Nibin Manu, Mullasari Ajit Sankaradas, Gaurav M. Upadhyay, Ulhas M. Pandurangi

Podcast Contributors

Michael S. Lloyd, MD, FHRS
Jason T. Jacobson, MD, FHRS
Miguel A. Leal, MD, FHRS

All relevant financial relationships have been mitigated.

Host Disclosure(s):

M. Lloyd

​Contributor Disclosure(s):

J. Jacobson

M. Leal

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.

Description

Join host and Digital Education Committee Member, Danesh Kella, MBBS, FHRS and his guests Ratika Parkash, MD, MS, FHRS and Prashanthan Sanders, MBBS, PhD, FHRS at HRX Live 2025 in Atlanta, for this exciting discussion.

The PRAGUE-25 trial, published in JACC in 2025, compared catheter ablation with a program of lifestyle modification plus antiarrhythmic drugs in obese patients (BMI 30–40 kg/m2) with symptomatic atrial fibrillation. At 12 months, freedom from atrial fibrillation was significantly higher with ablation (73%) than with lifestyle modification + AADs (35%), despite the latter group achieving greater weight loss and metabolic improvement. The findings suggest that while aggressive risk-factor control improves overall health, catheter ablation remains more effective for rhythm control in this population.

Learning Objectives

• Describe the comparative effectiveness of catheter ablation versus lifestyle modification with antiarrhythmic drug therapy in obese patients with symptomatic atrial fibrillation.
• Discuss how weight reduction and risk-factor modification influence atrial fibrillation outcomes, while recognizing that catheter ablation provides superior rhythm control despite metabolic improvements achieved through lifestyle intervention.

Article Authors

Pavel Osmancik, Tomas Roubicek, Stepan Havranek, Jan Chovancik, Veronika Bulkova, Dalibor Herman, Martin Matoulek, Vladimir Tuka, Ivan Ranic, Jana Hozmanova, Marek Hozman, Lucie Znojilova, Adam Latinak, Jan Pidhorodecky, Milan Dusik, Jan Simek, Otakar Jiravsky, Bogna Jiravska-Godula, Frantisek Lehar, Michal Cernosek, Zuzana Hejdukova, Hana Zelinkova, Jiri Jarkovsky, and Klara Benesova


Podcast Contributors

Prashanthan Sanders, MBBS, PhD, FHRS
Danesh Kella, MBBS, FHRS
Ratika Parkash, MD, MS, FHRS

All relevant financial relationships have been mitigated.

Host Disclosure(s):

D. Kella

​Contributor Disclosure(s):

R. Parkash

P. Sanders

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 host and HRS Digital Education Committee Vice-Chair, Tina Baykaner, MD, MPH and her guests Jerome Kalifa, MD and Paul C. Zei, MD, PhD, FHRS as they discuss this article at HRX 2025 in Atlanta.

The RESTART trial is an international, multicenter, non-randomized interventional study designed to assess whether using Volta Medical's AI-assisted algorithm to identify and ablate dispersed electrograms (EGMs) in addition to doing repeat pulmonary vein isolation can improve outcomes in patients whose atrial fibrillation recurred after previous ablations.The main goal is to see the proportion of patients who are free from AF twelve months after the repeat procedure (without antiarrhythmic drugs), and the trial contains about 92 patients.

Learning Objective

Describe the design and purpose of the RESTART trial, including how the use of AI-guided identification and ablation of dispersed electrograms aims to improve outcomes for patients undergoing repeat ablation for recurrent atrial fibrillation.

Article Authors

• John D. Hummel
• Haroon Rachid
• Isabel Deisenhofer
• Paul C. Zei
• Gustavo Morales
• Jerome Horvilleur
• Stavros Mountantonakis
• Jean-Paul Albenque
• Devi G. Nair
• Benjamin D'Souza
• Smit C. Vasaiwala
• Tom De Potter
• Daniel H. Cooper
• Mark Metzl
• Adi Lador
• Anthony R. Magnano
• Alexandru B. Chicos
• Joshua R. Silverstein
• Daniel Guerrero
• Shirley Beguin
• Anas El-Benna
• Sabine Lotteau
• Marie-Sophie Nguyen-Tu
• Paola Milpied
• Jerome Kalifa
• Bradley P. Knight
• Dhanunjaya R. Lakkireddy

Podcast Contributors

Jerome Kalifa, MD
Paul C. Zei, MD, PhD, FHRS
Tina Baykaner, MD, MPH

All relevant financial relationships have been mitigated.

Host Disclosure(s):

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

​Contributor Disclosure(s):

J. Kalifa:

P. Zei
•Research: Biosense 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.