EP Edge Journal Watch

Can anticoagulation be safely discontinued after successful atrial fibrillation ablation? Is the traditional prohibition against flecainide in structural heart disease too broad or does CAST remain an essential warning? And can AI-enabled ECGs, unipolar voltage mapping, and cardiac MRI improve how we detect AF and characterize arrhythmic substrate?
In EP Edge® Journal Watch Issue 32, Dr. Niraj Sharma examines important electrophysiology research published in Heart Rhythm and JACC: Clinical Electrophysiology, translating the methodology, statistical findings, limitations, and clinical implications into practical insights for electrophysiologists and cardiovascular clinicians.
Topics include:
Discontinuing oral anticoagulation after AF ablation
The clinical and economic consequences of delayed AF ablation
Estimating AF burden after several AF-free monitoring days
Multicenter validation of an AI-enabled ECG model for predicting AF
Unipolar voltage mapping and lesion durability after pulsed field ablation
High-density electroanatomic mapping versus cardiac MRI in nonischemic cardiomyopathy
How CAST changed the direction of flecainide research
Class Ic antiarrhythmic therapy after PCI
Reconsidering flecainide in selected structural heart disease phenotypes
Amiodarone-associated thyrotoxicosis in patients with pre-existing hypothyroidism
The episode separates statistical association from causal evidence and asks what these findings should and should not change in current practice. It also outlines the prospective trials needed to determine whether anticoagulation withdrawal, AI-guided AF screening, voltage-guided PFA, and phenotype-based flecainide prescribing can improve clinically meaningful outcomes.
Dr. Sharma also previews the next collaborative EP Edge® Journal Watch issue with the Heart Rhythm Society, the forthcoming EP Edge® app, and the new epedge.org platform—bringing podcasts, newsletters, EP Edge Rx, EP Edge Academy, and additional clinical and patient-focused resources into one accessible ecosystem.
References, graphics, and the complete written analysis are available through EP Edge® Journal Watch on LinkedIn and Substack:
https://epedge.substack.com
Questions, suggestions, or concerns: epedge.cast@gmail.com

In EP Edge® Journal Watch Issue 31, August 2026, Dr. Sharma examine new evidence that challenges several familiar assumptions in cardiac electrophysiology.
Should patients with atrial fibrillation routinely stop drinking coffee? An American Heart Association scientific statement reviews the cardiovascular effects of caffeine, including randomized evidence showing a 39% lower risk of recurrent AF among habitual coffee drinkers who continued coffee after cardioversion. The discussion separates ordinary coffee consumption from energy drinks and concentrated caffeine while considering premature ventricular contractions, blood pressure, sleep, and individualized patient counseling.
The episode also investigates whether wine adds cardiovascular benefit to the Mediterranean diet. The apparent benefit weakened when moderate drinkers were compared with very-light drinkers, demonstrating how the reference group can change the statistical narrative. Importantly, these studies did not evaluate AF outcomes and do not support prescribing wine as cardiovascular therapy.
Other studies covered include:
• Pulsed-field ablation for persistent AF, with pooled one-year freedom from atrial arrhythmia of 72.3%, but no proven superiority over thermal ablation.
• Broad and predominantly left-sided pulmonary vein reconnection patterns during redo procedures after pentaspline pulsed-field ablation.
• Real-world Sphere-9 safety reports involving ventricular arrhythmias, implanted-device interactions, stroke, AV block, and other signals, interpreted in the absence of a procedural denominator.
• The SMARTBEATS randomized trial of smartphone rhythm monitoring before cardioversion, which prevented approximately one same-day cancellation for every six patients monitored.
• Autopsy-based sudden cardiac death research showing that myocardial infarction accounted for 41% of confirmed sudden cardiac deaths and highlighting the limitations of ejection fraction alone.
• End-tidal carbon dioxide trajectories during out-of-hospital cardiac arrest and why no single value should become a stand-alone termination rule.
• Atrial fibrillation, bradycardia, conduction disease, and ventricular ectopy in masters athletes, reinforcing that exceptional fitness does not provide immunity from clinically important arrhythmias.
Listen for the study rationale, methodology, clinically meaningful statistics, limitations, and the EP Edge take on how these findings may influence practice.
Complete references, graphics, and detailed analysis are available through the LinkedIn newsletter EP Edge® Journal Watch and at epedge.substack.com.

In EP Edge® Journal Watch Issue 30, July 2026, we explore the next phase of cardiac electrophysiology, from pulsed field ablation durability and physiologic pacing to neuromodulation, sleep, fitness, and lifetime arrhythmia risk.
We begin with the first-in-human VISION AF study, which evaluates an endoscope-enabled pulsed field ablation balloon that allows direct visualization of the electrode-tissue interface. Chronic invasive remapping provides a close look at pulmonary vein isolation durability and raises an important question: could seeing tissue contact become the next major advance in PFA workflow? 
Two additional studies examine practical PFA safety signals. One evaluates hemolysis-associated acute kidney injury, pulse count, chronic kidney disease, extensive left atrial ablation, and whether protocol-based hydration can reduce renal risk. Another quantifies acute blood pressure drops during circular-array PFA and identifies the first pulmonary vein treatment as the period of greatest hemodynamic vulnerability. 
The pacing and ventricular arrhythmia section includes:
 The randomized PACE-HF trial, comparing left bundle branch area pacing with conventional right ventricular pacing 
 A preclinical comparison of left bundle branch area antitachycardia pacing and right ventricular ATP 
 Pulsed ultrahigh-frequency spinal cord stimulation as a potential neuromodulation strategy after myocardial infarction 
We then move beyond the EP laboratory to examine:
 Insomnia and incident atrial fibrillation 
 The lifetime cardiovascular tradeoff between high cardiorespiratory fitness and AF risk 
 Whether the balance of moderate and vigorous physical activity influences cardiovascular and overall mortality 
Each paper is examined through its rationale, methodology, statistical meaning, limitations, and potential clinical consequences.
Can direct tissue visualization improve PFA durability? Should PFA pulse count be treated as a biologic dose? Is right ventricular pacing still acceptable when substantial pacing is anticipated? Could the site of antitachycardia pacing determine whether VT terminates? How should clinicians incorporate sleep and exercise into arrhythmia prevention?
This episode is intended for electrophysiologists, cardiologists, device specialists, fellows, researchers, and anyone following advances in pulsed field ablation, conduction system pacing, ventricular arrhythmia therapy, and preventive cardiology.
Read the companion newsletter and subscribe to EP Edge® Journal Watch at epedge.substack.com.

In EP Edge® Journal Watch Issue 29, July 2026, we examine the evidence reshaping contemporary atrial fibrillation management and the rapidly changing role of catheter ablation.
Two major meta-analyses compare catheter ablation with antiarrhythmic drug therapy, addressing rhythm efficacy, serious adverse events, hospitalization, treatment intolerance, and whether medications still deserve an automatic safety advantage. We also review real-world outcomes in older adults after prior antiarrhythmic drug exposure and ask whether another medication or catheter ablation is the more appropriate next step. 
The episode then explores whether ablation can modify the natural history of AF. A CABANA analysis evaluates progression from paroxysmal to persistent AF, while new registry data challenge the assumption that asymptomatic AF represents a low-risk phenotype. The SUPPRESS-AF analysis examines whether low-voltage area ablation should be guided by the amount of abnormal atrial substrate rather than applied uniformly. 
We also discuss:
 Urgent versus elective inpatient AF ablation 
 Oral anticoagulation after apparently successful AF ablation 
 The age-dependent relationship between heart failure and ischemic stroke 
 The SLASH score for predicting AF recurrence after electrical cardioversion 
Each study is reviewed through its clinical rationale, methodology, statistical interpretation, limitations, and practical implications for electrophysiology practice.
Should catheter ablation move earlier in the AF treatment pathway? Should symptom status continue to determine access to rhythm control? When is urgent inpatient ablation justified? Does successful ablation ever eliminate the need for anticoagulation?
This episode is designed for cardiac electrophysiologists, cardiologists, fellows, researchers, and clinicians seeking a detailed, clinically relevant review of the latest atrial fibrillation evidence.
Read the companion newsletter and subscribe to EP Edge® Journal Watch at epedge.substack.com.

In this July 2026 episode of EP Edge Journal Watch, produced in collaboration with the Heart Rhythm Society (HRS), Mike Lloyd and Dr. Niraj Sharma review five studies with direct implications for contemporary cardiac electrophysiology practice.
The anchor trials are InEurHeart, a randomized comparison of computed tomography-guided versus conventional catheter ablation for post–myocardial infarction ventricular tachycardia, and OPINION, which evaluates prophylactic surgical left atrial appendage occlusion during valvular heart surgery in patients without known pre-existing atrial fibrillation. Using the workflow gains seen with pulsed field ablation in AF as context, the discussion asks whether preprocedural cardiac CT can make ischemic VT ablation more efficient while preserving the essential role of functional mapping and why future AF risk should not automatically lead to surgical LAA closure.
Rapid-fire analyses cover the relationship between alcohol consumption and incident atrial fibrillation, pulse self-examination as a simple strategy to improve AF detection, and emerging mechanistic research on caveolae, pacemaker signaling, sinus node dysfunction, and heart failure.
The episode translates randomized trials, meta-analysis, screening research, and translational science into practical implications for the EP lab, clinic, patient counseling, and shared decision-making. Essential listening for electrophysiologists, cardiologists, fellows, advanced practice clinicians, and cardiac rhythm-management teams