Key trends in electrophysiology include PFA, dual-chamber leadless pacemakers

Overall, outcomes and efficacy of PFA are about the same as cryo and radiofrequency (RF) ablation, but the safety profile gained by its ability to not damage critical structures under the target tissue has made EPs excited about this technology. While rare, an ablation that burns through to the esophagus can be catastrophic for a patient and even fatal. 

Emerging ablation techniques discussed at HRS

Ellenbogen said early work was also presented on applying PFA for ventricular arrhythmias, which he said holds promise, with more data anticipated next year.

Another new innovation was the use of ultra-cold cryoablation for ventricular arrhythmias, which he said presents a new frontier for arrhythmia treatment. 

Dual-chamber leadless pacing

Ellenbogen highlighted the transformative potential of dual-chamber leadless pacemakers. The U.S. Food and Drug Administration approved Abbott’s Aveir DR leadless pacemaker system in July 2023. It was the world’s first dual-chamber leadless pacing system, with Aveir catheter-implanted pacemakers placed in each ventricle. The devices then communicate with each other to adjust pacing for both sides of the heart. 

Leadless pacemakers have been around for several years, but the majority pf patients that need a pacemaker need a dual-chamber device. The new system has now opened up leadless pacing to all patients.  

"That's a whole new technology that is really going to transform our field," Ellenbogen explained. 

Left bundle branch pacing and its implications

Left bundle branch pacing was also a big topic this year. Rather than using two leads to pace each ventricle in left bundle branch block (LBBB) patients, a single lead can be placed in the LBB located in the septum after the area of block. While this can simplify pacemaker procedures and reduce the amount of hardware put inside a patient, there are some challenges with the anatomy and exact location of where top place a lead that can be more complex.

"It's a little bit more difficult probably for many patients who have relatively good heart muscle function. It probably doesn't make that much difference whether you pace the septum or whether you pace the septum and get their conduction system captured. But in patients who have heart failure, it does make a big difference," Ellenbogen explained.

LBB pacing can perform even better than cardiac resynchronization therapy in most cases, Ellenbogen added.

Artificial intelligence may be the future of arrhythmia management

One of the most exciting developments is the integration of artificial intelligence (AI) in electrophysiology and its application in mapping system algorithms. Ellenbogen described new AI-driven algorithms designed to determine ablation targets beyond pulmonary veins for persistent AFib. 

"I think one of the most exciting algorithms we saw was using AI to determine in a patient who has persistent AF what other areas to ablate other than the pulmonary veins. That is a question that has been tying us for almost 20 years, and we've tried to blame the posterior wall. We've tried ablating complex fractionated electrograms. No clinical trial has been able to demonstrate a benefit. So finally we have a clinical trial using AI, using electrical recordings from an individual patient with a strategy that's better than pulmonary vein isolation. That's super exciting," Ellenbogen explained.

He believes this is just the tip of the iceberg and we will likely see a lot of AI generated algorithms that help EPs localize arrhythmias and predict when patients are going to have AFib. 

"This is going to change our field dramatically over the next decade or two," he concluded.