PFA's dominance and other key electrophysiology trends on display at Heart Rhythm 2026
Cardiac electrophysiology (EP) is in the middle of a rapid transformation driven by advances in pulsed field ablation (PFA), device miniaturization and a growing integration of digital tools, according to Heart Rhythm 2026 program chair Dhanunjaya "DJ" Lakkireddy, MD, MBA, executive medical director of the Kansas City Heart Rhythm Institute and a professor at the University of Kansas Health System. Lakkireddy spoke to Cardiovascular Business at Heart Rhythm 2026 to review some of EP's biggest trends.
"The field of EP is at an unprecedented inflection point with the intersection of amazing new technology with well-proven devices that have formed the foundation stone for the growth of electrophysiology. So I think the future is looking incredibly amazing and bright," he said.
Pulsed field ablation reshapes the EP landscape
The most dominant trend at the 2026 meeting was PFA, a non-thermal energy modality that uses precisely directed electrical fields to cause cell death and increase patient safety. He said it has quickly moved from experimental to mainstream use.
“PFA has essentially taken over the EP space,” Lakkireddy said, estimating that penetration in the United States could now be 95% or more.
The technology’s appeal stems from its safety profile in preventing rare, but catastrophic complications such as damage to the esophagus and nerves. He said multiple manufacturers are introducing new catheter designs, energy waveforms and delivery approaches. However, as use expands, clinicians are also gaining a more nuanced understanding of its limitations, such as very rare complications.
“We’re learning more about potential issues like hemolysis, coronary vasospasm and very rare cases of sudden cardiac death,” he said. “The field is maturing, and we’re trying to better understand these signals.”
Rather than replacing legacy technologies entirely, PFA is expected to coexist with radiofrequency ablation (RFA). Lakkireddy predicted a “dual-energy” future, where physicians tailor energy sources to specific cardiac structures.
“In certain areas, particularly thicker tissue or regions prone to vasospasm, RFA still has a role,” he explained. “Combination approaches using both PFA and RFA may ultimately offer the best outcomes.”
Improved durability in AFib ablation
Advances in PFA and high-density EP electromapping systems are also improving one of the longstanding challenges in atrial fibrillation treatment with durable pulmonary vein isolation.
Earlier-generation technologies required repeat procedures in up to a third of patients, but newer technologies are delivering more consistent results.
“Durability is significantly better than it has ever been,” Lakkireddy said. “We’re seeing improved first-pass isolation and better long-term outcomes.”
However, he emphasized that ablation alone cannot address the full complexity of AFib, particularly in persistent disease.
“We still need a better understanding of disease progression and underlying pathophysiology,” he said. “Technology alone is not enough.”
Leadless pacing and next-generation devices gain traction
On the device side, innovation is accelerating around leadless pacing systems and novel implantable cardioverter-defibrillator (ICD) platforms. Leadless pacemakers are expanding beyond right ventricular pacing into more advanced applications, including left bundle branch area pacing, which was a major focus at Heart Rhythm 2026.
Using a modified leadless pacemaker and an implantation technique using transjugular access, Lakkireddy said physicians can achieve physiologic pacing similar to traditional transvenous systems, with improvements in QRS duration and cardiac function.
An additional innovation includes an ultrasound-activated, tiny, leadless left ventricular implant that may enable fully leadless cardiac resynchronization therapy.
“These are early-stage technologies, but they represent an exciting new frontier,” Lakkireddy said.
Meanwhile, subcutaneous and extravascular ICDs (S-ICDs) are gaining momentum, particularly for patients who do not require pacing support. Newer iterations are addressing earlier limitations such as discomfort and unintended stimulation.
“There’s growing interest in combining leadless pacing systems with subcutaneous ICDs,” he added. “This kind of modular approach allows for more personalized therapy.”
Convergence with heart failure management
Another emerging trend in EP is the integration of these devices with heart failure monitoring and management tools.
Next-generation systems under development aim to combine rhythm management with physiologic sensing, such as myocardial strain analysis, potentially offering earlier insights into cardiac dysfunction.
“This could become a foundational tool for assessing myocardial contractility and managing heart failure alongside arrhythmias,” Lakkireddy said.
AI, digital monitoring and a broader care model
Beyond hardware innovations, wearable heart monitors that offer real-time insights and artificial intelligence (AI) are expected to play an increasingly central role in EP diagnostics.
Beyond wearable rhythm monitoring, AI-enabled mapping systems are being developed to improve procedural precision.
“Machine learning algorithms can help identify arrhythmia origins and better define substrates,” Lakkireddy said. “This will make procedures more efficient and safer.”
He also highlighted the need for a more comprehensive, team-based approach to care, particularly for atrial fibrillation patients. Risk factors such as obesity, hypertension, diabetes and sleep apnea remain critical drivers of disease progression, yet are often under-addressed in EP workflows.
“We’ve become very focused on procedures, but we need to return to the fundamentals,” he said. “Lifestyle management, risk factor control and preventive strategies are essential.”
He pointed to emerging therapies, including GLP-1 receptor agonist drugs as potential tools to complement interventional treatments.
He said all these technologies taken together, the trends on display at Heart Rhythm Society (HRS) annual meeting reflect a field at a pivotal moment, where rapid technological advancement is intersecting with a growing recognition of the need for holistic patient care.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]