Jarkko Karvonen

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.

Background: Remote monitoring (RM) enables convenient follow-up of patients with cardiac implantable electronic devices. In remote-only monitoring (RM-only) in-person visits are only scheduled if needed based on RM findings. This study evaluated the feasibility and safety of long-term RM-only of pacemaker (PM) patients. Methods: All patients with Biotronik PM were included in the analysis. Data on the number and causes of additional in-office device interrogations, actions due to the transmissions, hospitalizations and performance of RM were collected from a large cohort of pacemaker patients followed by RM-only. Results: In total 606 patients (302 female) with mean age of 78±12 years were included in the analysis. During the mean follow-up of 2.8 years 445 additional in-office device interrogations were made in 287 patients (0.3 interrogations / year), and in 110 (25%) of these cases changes to device programming were made. In a subgroup analysis of 100 patients with at least one year of prior appointment-based device monitoring, the need for in-office visits was 6.9 times higher per follow-up year than in RM (IRR=6.9, 95% CI 4.9-9.9; p<0.001). The hospitalization rate in the entire cohort during RM was 0.3 / year with no difference in the rate of hospitalizations between the two monitoring methods (IRR 1, 95% CI 0.8-1.4, p=0.8). The success of daily transmissions was 91.7 %. Conclusion: Our real-word data indicate that RM-only offers an efficient and safe method for long-term follow-up of pacemaker patients.

Aims: Patients with persistent atrial fibrillation (AF) and heart failure (HF) have compromised clinical outcomes. Contemporary management includes rhythm control with AF ablation, or rate control and regularization with conduction system pacing and atrioventricular nodal ablation (CSP + AVNA). These strategies have never been compared in a randomized clinical trial. The study aims to determine whether CSP + AVNA is superior to AF ablation for reducing all-cause mortality and cardiovascular hospitalization, and noninferior with respect to all-cause mortality and heart failure hospitalization. Methods and results: ABACUS is a multicentre, investigator-initiated, randomized controlled trial enrolling 220 patients with persistent AF and HF, aged >60 years, who are eligible for both treatment modalities, with at most one previous AF ablation procedure. Participants will be randomized 1:1 to either catheter ablation of AF (with pulmonary vein isolation using any routine technique) or to CSP + AVNA. All patients will undergo at least one year of follow-up. The co-primary endpoints will be tested sequentially. A number of predefined secondary endpoints, including costs, will also be evaluated. Discussion: ABACUS compares CSP + AVNA with AF ablation in patients with persistent AF and HF. The results will provide evidence to improve care in this vulnerable patient population.

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.

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: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. However, the optimal strategy during repeat ablation is not clear. This European Heart Rhythm Association (EHRA) survey aims to assess real-world ablation strategies in patients undergoing repeat AF ablation. Methods and results: A 25-item questionnaire was distributed among healthcare professionals via EHRA between 22 May and 21 June 2024. Of the 211 respondents from 43 countries, 58.1% of respondents planned a redo after multiple symptomatic recurrences of atrial arrhythmias. Most repeat procedures (68.0%) are performed within 3 months after the decision for re-intervention. 3D mapping and radiofrequency (RF) catheters with contact force (CF) sensing are the most common modality used for repeat ablation. In patients with more than one pulmonary vein (PV) reconnection, most commonly reisolation of the PVs plus individualized substrate-based ablation is performed (62.2%). When empirical ablation is performed, the most common targets include cavotricuspid isthmus (22.5%), posterior wall isolation (20.7%), left atrial roofline (16.1%), anterior line (12.9%), superior vena cava (8.6%), and vein of Marshall (8.6%). In patients without PV reconnection at repeat procedure, substrate mapping/individualized ablation is the preferred strategy (77.9%). No additional right atrial ablation beyond the CTI was reported. The majority of respondents (60.7%) consider rate control after ≥3 failed ablations. Conclusion: Real-world strategies for repeat AF ablation show significant variability. 3D mapping and CF-guided RF ablation are commonly utilized. Re-PVI and substrate-based ablation are the predominant approaches. However, the optimal strategy beyond durable PVI remains to be further evaluated.

Conduction system pacing (CSP) is being increasingly adopted as a more physiological alternative to right ventricular and biventricular pacing. Since the 2021 European Society of Cardiology pacing guidelines, there has been growing evidence that this therapy is safe and effective. Furthermore, left bundle branch area pacing was not covered in these guidelines due to limited evidence at that time. This Clinical Consensus Statement provides advice on indications for CSP, taking into account the significant evolution in this domain.

BACKGROUND: Remote monitoring offers an effective and safe method for monitoring patients with cardiovascular implantable electronic devices. The downside of remote monitoring is the overflow of the data. Since many of the remote monitoring transmissions are nonactionable, optimizing alert transmissions could partly overcome this problem. METHODS: We collected data on the number and the causes of all alert-, scheduled-, and patient-initiated transmissions as well as actions initiated by these transmissions in 2023. According to our strategy, all clinically nonrelevant alerts were turned off. The trend of alert transmissions and the proportion of actionable scheduled transmissions are presented. The patient safety was monitored by analyzing the premortem alerts and changes to alert settings in deceased patients, as well as the rate of actionable scheduled or patient-initiated transmissions during follow-up. RESULTS: During the study period 8182 transmissions were generated from 3732 cardiovascular implantable electronic devices. Of these, 2306 (28%) were alert transmissions, of which 57% (n=1290) were considered clinically nonrelevant. The rate of alerts decreased by 44% from January to December (0.07 versus 0.04 per device per month, P =0.001). Of the 3335 scheduled transmissions, 11% (364) were actionable, and the proportion of actionable scheduled transmissions remained unchanged during the follow-up period ( P =0.08). Notably, none of the deaths were linked to the adjustment of alert settings. CONCLUSIONS: Our data indicated that active evaluation of the clinical relevance of all alert transmissions and deactivation of clinically nonrelevant alerts reduce the remote monitoring workload. However, long-term follow-up is needed to ensure that patient safety is not compromised.