Electrophysiology: Important EP Updates from 2023

Heart Rhythm 2023: Innovations in Ablation, Devices, and Conduction System Pacing.

Catheter Ablation and LAAO Advance:

• CASTLE-HTx: Ablation for AF proved beneficial in patients with advanced heart failure, potentially paving the way for wider adoption.
• Pulsed-field ablation (PFA): PULSED AF and ADVENT trials showed promise for novel PFA technologies like PulseSelect (Medtronic) and Farapulse (Boston Scientific).
• Left atrial appendage occlusion (LAAO): WATCH-TAVR confirmed LAAO safety and efficacy alongside TAVI in severe aortic stenosis and AF.
• Updated AF guidelines: Both US and European guidelines incorporated advancements in ablation, LAAO, and medications.

Medical Therapies: Mixed Bag:

• NOAH-AFNET 6: Edoxaban (Savaysa) increased risks in patients with subclinical AF detected by implanted devices.
• ARTESiA: Apixaban (Eliquis) reduced stroke but increased major bleeding in subclinical AF patients.
• Meta-analysis: DOACs reduce ischemic stroke but significantly increase major bleeding in subclinical AF.
• AZALEA-TIMI 71: Abelacimab (Anthos Therapeutics) showed promise for reducing bleeding compared to rivaroxaban in AF patients.
• ReVeRA-201: Etripamil nasal spray effectively reduced ventricular rate in AF with rapid ventricular rate.
• FRAIL-AF: Switching frail elderly AF patients from warfarin to DOACs increased bleeding risks.

Pacing and ICDs: Conduction System Pacing Takes Center Stage:

• Large observational study: LBBAP outperformed biventricular pacing in CRT patients.
• HOT-CRT pilot study: His-bundle pacing improved LV function more than biventricular pacing in CRT candidates.
• EHRA consensus statement: Standardized implantation technique for conduction system pacing.
• DANPACE II: Reducing atrial pacing in sinus node dysfunction patients did not lower AF risk but increased presyncope/syncope.
• US FDA approves first EVICD: Aurora EV-ICD by Medtronic avoids transvenous lead complications.