Michał Mazurek

Aims: Disparities in arrhythmia care are increasingly recognized, yet remain incompletely characterized across the patient pathway. This European Heart Rhythm Association (EHRA) survey explored clinician-reported perceptions of inequity across diagnosis, pharmacological management, procedural referral, and follow-up. Methods and results: A 30-question survey was disseminated via the EHRA between November 2025 and January 2026, with 212 responses from professionals across 35 countries. Respondents were predominantly consultant electrophysiologists (67.5%), with 39.6% identifying as female. Most (68.4%) reported no prior training in equity or inclusive care. Across the arrhythmia care pathway, disparities were most frequently attributed to patient vulnerability, particularly cognitive impairment (72.5%), age >80 years (63.8%), and mental health disease (61.3%). Differences related to socioeconomic status, language, and other social factors were also commonly reported. Female sex and minority ethnic background were each reported to influence care in 24.1% of responses. Age >80 years was consistently identified as the strongest determinant of disparities in referral, diagnosis, and outcomes, influencing referral for arrhythmia evaluation (65.8%), catheter ablation (77.9%), and outcomes following ablation (68.1%). Socioeconomic and ethnic factors showed more modest but consistent effects, while sex-based differences were less frequently reported. However, female respondents were more likely than male respondents to report delayed referral (female respondents: 41.8%; male respondents: 19.8%) and late or incorrect diagnosis (49.4 vs. 15.8%) in female patients, as well as delayed referral for catheter ablation (36.5 vs. 10.3%) and device implantation (23.0 vs. 7.0%). Only one-third of respondents (33.3%) felt that current international guidelines adequately address diversity, equity, and inclusion in arrhythmia care. Conclusion: Clinicians perceive disparities in arrhythmia care across multiple patient and social factors. Whilst age and vulnerability were most frequently perceived to influence care, sex and ethnicity were also recognized by a substantial proportion of respondents. Perceptions varied according to respondent characteristics, with female clinicians more likely to report disparities amongst female patients. Limited training and institutional frameworks highlight opportunities for targeted interventions.

Aims: Pulsed field ablation (PFA) has rapidly emerged as a non-thermal ablation technology for pulmonary vein isolation (PVI), with an unprecedented adoption across Europe. The aim of this survey was to characterize current practice patterns. Methods and results: The European Heart Rhythm Association (EHRA) Scientific Initiatives Committee designed a 30-item questionnaire addressing temporal adoption of PFA, pre-, intra-, and post-procedural workflows, and future perspectives. The survey was distributed between April and June 2025. A total of 216 responses were obtained from 43 countries. At the time of the survey, 23% of respondents had not yet initiated a PFA programme. Overall, PFA is now used in half (49%) of first atrial fibrillation (AF) ablation procedures. Adoption was significantly higher in high-volume centres and ‘Western European’ countries. The primary driver for adoption was time efficiency (60%). Intra-procedural workflows showed marked heterogeneity: approximately half of the operators relied exclusively on fluoroscopy without any intra-procedural imaging/mapping. Additional ablation lesions beyond PVI were common, with one-third employing standardized PVI+ protocols in persistent AF, most frequently posterior wall isolation. General anaesthesia and deep sedation were used in equal proportions. Conclusion: This EHRA survey demonstrates both rapid implementation and significant heterogeneity in PFA use across Europe. Standardized protocols and prospective studies are needed to define best practices.

Aims: Atypical atrial flutter (AAFl) encompasses a diverse group of macro-reentrant arrhythmias with variable circuits, presenting diagnostic and therapeutic challenges. This European Heart Rhythm Association (EHRA) survey aimed to assess current practices across European centres regarding the management of AAFl. Methods and results: A 26-item online questionnaire distributed by the EHRA Scientific Initiatives Committee yielded 214 responses from physicians in 36 countries. Catheter ablation was considered first-line therapy by 67.6% of respondents. In patients presenting in sinus rhythm with non-inducible clinical AAFl at the time of ablation, management strategies were heterogeneous, with combined pulmonary vein isolation and substrate ablation being the most common approach (46.8%). Activation mapping was the preferred method to define the circuit (63.7%), ahead of entrainment manoeuvers. Most respondents (87.1%) used ablation lines connecting scar or unexcitable tissue, whereas only 7.5% targeted the critical isthmus alone. The most frequent endpoints were validation of conduction block (73.1%), interruption of the clinical arrhythmia (71.0%), and non-inducibility of the clinical flutter (56.5%), while non-inducibility of any atrial flutter was rarely pursued. In patients without prior cardiac intervention, the left atrial anterior wall was perceived to be the most frequently involved structure (59.4%). Finally, in case of recurrence, 74.3% of respondents preferred redo ablation. Conclusion: This EHRA survey reveals consensus on ablation endpoints but marked variability in ablation timing and strategies when AAFl is non-inducible at the time of ablation, underscoring the need for standardized protocols and further collaborative research to optimize outcomes.

Background: Traditional cardiac resynchronization therapy (CRT) is an effective treatment for patients with heart failure. Objective: The study aimed to determine the long-term durability of CRT leads, factors predisposing to replacement, and the outcomes of lead replacement in CRT patients. Methods: The study population consisted of 1059 consecutive patients with conventional CRT implanted between 2002 and 2019 in a university hospital. Results: During the median follow-up of 1661 days (IQR: 815–2792), a total of 324 leads were replaced in 251 patients (23.7%) for non-infectious reasons. Of those who required lead replacement, 126 subjects (50.2%) had the procedure within the first year since CRT implantation. In patients followed over ten years (n=143; 13.5%), 67 subjects (46.8%) had one or more lead replacements. Duration of index CRT procedure and fluoroscopy time were independent predictors for lead replacement in a multivariable analysis (HR 1.03, 95% CI 1.01–1.06, P=0.02 and HR 1.11, 95% CI 1.02–1.15, P=0.01, respectively). Leads that required replacement were left ventricular (11.2%), right ventricular (10.8%), and right atrial (4%), respectively. As compared with no need for re-intervention, lead-related re-do procedures did not influence overall long-term mortality (55.3% vs 51%, P=0.3) nor incidence of device-related infective endocarditis (5.6% vs 4.5%, P=0.82). Conclusions: Almost 25% of patients with CRT require lead replacement within 4.5 years due to non-infectious reasons, and half of those need replacement within the first year. In ten years, nearly every second patient requires a lead-related re-do procedure. Lead replacement does not affect long-term all-cause mortality.

Aims: Device-detected subclinical atrial fibrillation (DDAF) is increasingly documented either with implantable cardiac electronic devices (CIED) or with consumer-based mobile or wearable monitors. We aimed to investigate phisician's reaction to DDAF, which management is still matter of debate. Methods: This is a physician-based survey with 24 multiple-choice questions. Results: A total of 222 physicians from 46 countries responded the survey. DDAF is frequent, occurring in >10% of CIEDs follow-up for 37% of respondents. Oral anticoagulation is prescribed according to CHA2DS2-VA and AF duration; 34% of the respondents initiate anticoagulation with AF >24 h, 26% with AF >6 h, and 15% with AF >5–6 min. Respondents from non-European countries and Mediterranean Europe are more likely to prescribe diagnostic exams and therapy than respondents from North Europe. Systematic long-term AF screening with implantable loop recorder (ILR) after cryptogenic stroke ranges from 43 ± 27% of ILR implanted for that purpose in Mediterranean countries to 10 ± 20% in North Europe. The majority of responders recommends the use of consumer-based devices to screen for AF mainly in specific situations (undiagnosed palpitations, ischaemic stroke, or AF burden monitoring) and not routinely, just according to CHA2DS2-VA or age. Conclusion: AF screening is not routinely performed, either in primary or secondary prevention of stroke. Device-detected AF is not uncommon and generally managed based on thromboembolic risk and duration of episodes; the cut-offs of AF duration, global burden, and number of episodes are yet to be determined in terms of role and clinical value. Clinicians’ approaches to subclinical AF remain heterogeneous.

Aims: Reliable vascular access and haemostasis techniques are important to the safety of electrophysiology (EP) procedures. This European Heart Rhythm Association (EHRA) survey aimed to evaluate contemporary vascular access site management practices across international EP centres. Methods and results: A 30-question survey was disseminated via the EHRA between March and April 2025, with 401 responses from professionals across 51 countries. Most respondents were cardiology consultants/attendings (82.0%), with 57.3% performing over 150 EP procedures annually. Ultrasound guidance for vascular access was usually or always used by 71.7%, though 21.4% used it rarely or never, and only 17.3% had received formal ultrasound training. Institutional protocols for haemostasis were lacking in around half (46.8%) of centres. Suture-mediated closure was the most common method for haemostasis (60.4%), followed by manual compression (33.0%) and vascular closure devices (VCDs, 5.8%). The figure-of-eight suture with a hand-tied knot was the most frequently used suture technique (79.7%). Just over a third (36.0%) had experience with VCDs, typically reserved for high-risk cases. For procedures requiring transeptal access, 38.1% administered heparin before transeptal puncture, while protamine was rarely or never used by 62.1%. Anticoagulation was partially interrupted in 52.1% and continued uninterrupted in 41.1% of routine atrial fibrillation (AF) ablations. The median bed rest duration post-procedure ranged from 4 h (right-sided EP procedures) to 6 h (AF or left-sided EP procedures). The average quoted vascular complication risk during consent was 3% (inter-quartile range 1–5%). Conclusion: This survey highlights marked variation in vascular access site management during and following EP procedures, emphasizing the need for further clinical trials to inform best practice and guide future standardization efforts.

Background: We aimed to assess the extent to which drug persistence is better with non-vitamin K antagonist oral anticoagulants (NOACs) than vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients and to estimate the difference in therapy persistence depending on NOAC dosing regimen (once daily (QD) vs. twice daily (BID)). Methods: Consecutive patients were followed for 1 year in phase III of the GLORIA-AF registry. Drug persistence was defined as the use of OAC without any discontinuation in >30 days or switching to alternative therapy. Results: Among 21,109 eligible patients in phase III, 17,266 patients who were prescribed OAC at baseline and those who took ≥1 OAC dose were included. The 1-year proportion of patients receiving NOAC and VKA who persisted on treatment was 80% and 75%, respectively. The 1-year persistence with NOACs BID and NOACs QD was 81% and 80%, respectively. Female gender, hypertension, older age, alcohol use, permanent, asymptomatic, and minimally symptomatic AF were associated with better OAC persistence. Region, medication usage predisposing to bleeding, being a current smoker, treatment reimbursement, and proton pump inhibitors were associated with lower OAC persistence. Conclusions: Drug persistence was higher with NOACs (1-year persistence was 80%) than with VKAs (75%). There was little difference in 1-year persistence between NOAC dosing regimens.