Subscribe
Share
Share
Embed
EP-EDGE brings you the latest in cardiac electrophysiology — from breakthrough research and clinical insights to future-shaping innovations. Hosted by Dr. Niraj Sharma, an electrophysiologist with over 15 years of experience, each episode delivers clear, evidence-based updates designed to inform, inspire, and elevate your practice.
Hi everyone. Welcome to EPH podcast. I'm Doctor. Niraj Sharma, electrophysiologist, the voice behind the EP Edge newsletter. If you've been following our journey on LinkedIn, you already know that EP Edge was born out of a simple idea to share meaningful cutting edge electrophysiology insights with our community.
Dr Niraj Sharma:But today, mark something new. With this podcast, my goal is to go beyond written words to connect, to converse, and to bring EP closer to where you are, whether that's during your morning commute, post procedure wind down, or that quiet moment between cases, if you have any. I also want this podcast to reflect something I believe in deeply, the power of human intelligence amplified by artificial intelligence. Each episode will bring you the best of both worlds: clinical expertise from real world EPIC practice and intelligent AI narration to make complex information more accessible, more consistent, and more scalable. In other words, expert insight amplified.
Dr Niraj Sharma:You'll hear updates on the latest clinical trials and technologies, conversations with thought leaders, and quick EP minutes packed with practical pearls for clinicians, APPs, fellows, and students. Whether it's pulse field ablation, stroke prevention strategies, or pacing frontiers, we'll explore not just what's happening, but why it matters. And now as part of the first episode, I'd like to bring you something familiar in a new format. Our EPH newsletter narrated by AI, this is from May 2025, where we deep dive into pulse field ablation. Thank you and enjoy.
AI 1:Let's dive in. Today we're really unpacking some critical updates in electrophysiology.
AI 2:Yeah. Focusing on two big things. Right? Pulse field ablation, PFA, and also how AI is starting to play a role.
AI 1:Exactly. PFA, you know, it came with this huge promise, ultra selective non thermal. Sounds amazing.
AI 2:It does. Yeah. But now we're seeing a wave of real world data, and, we need to look closely, especially at the systemic side effects.
AI 1:Right. So that's our mission here. Cut through the buzz and get to what you really need to know from this latest research.
AI 2:Okay. So where do we start? Maybe with that promise of non thermal ablation.
AI 1:Yeah. Let's do that.
AI 2:Well, the Nemesis PFA registry is a good place. They look at non target tissue injury, comparing PFA with mostly RF ablation, about eight hundred and seventy patients.
AI 1:And what they found about systemic burden, it was. Well, surprising, wasn't it?
AI 2:It really was. I mean, massive measurable burden after PFA.
AI 1:And the scale of it is what gets me. If PFA is truly non thermal, why on earth are troponin levels like a 100 times higher compared to RF?
AI 2:Yeah, that's the key question. It sort of challenges that core assumption, doesn't it?
AI 1:It absolutely does. What could be happening?
AI 2:It suggests that even if the energy is selective for heart muscle cells, maybe it's causing some kind of micro injury elsewhere or indirectly.
AI 1:And it wasn't just troponins, right?
AI 2:No, definitely not. The registry showed significant jumps in markers for hemolysis. You know, red blood cell breakdown, LDH and plasma free hemoglobin were way up.
AI 1:So this isn't just some minor lab finding. This points to a real physiological impact.
AI 2:Exactly. And then there's the direct hit to the heart muscles function.
AI 1:You mean the left atrial ejection fraction, the LAEF?
AI 2:Yes. That dropped by a whopping 20% after PFA. Compare that to just 5% after RF.
AI 1:20%. That's a huge difference in how well that chamber is pumping right after procedure.
AI 2:It is. And importantly, they saw a clear dose response relationship.
AI 1:Meaning more PFA lesions led to more systemic injury?
AI 2:That's right. So it kinda pushes back on the idea that PFA is just inherently gentler because it avoids heat.
AI 1:It seems we're maybe trading one type of injury, thermal, for another more complex systemic and hematologic burden.
AI 2:A burden we're only just starting to really quantify, I think.
AI 1:Okay. So let's pivot slightly. Because these systemic effects, they might tie into some of those rare but really serious risks clinicians worry about.
AI 2:Like silent strokes.
AI 1:Yeah. Exactly. Let's talk about silent cerebral lesions. Where was that Miyazaki study?
AI 2:Right. Finding silent strokes in, what was it, half of PFA patients?
AI 1:Half. But the kicker was that most of them, like over eighty five percent, weren't tiny little spots. They were medium to large lesions on the MRI scans.
AI 2:And particularly with certain types of catheters, the variable loop ones.
AI 1:So this isn't just, you know, some imaging artifact. It suggests real embolic risk that needs watching.
AI 2:Definitely. And linking back to that hemolysis we mentioned.
AI 1:Ah, the coronary spasm case. That was frightening.
AI 2:It really was. The Luther case report of 53 year old guy, procedure goes fine. Everything looks good.
AI 1:And then forty five minutes later?
AI 2:Yeah. Delayed, diffuse right coronary artery spasm, cardiac arrest, just catastrophic.
AI 1:And the proposed link is directly back to that PFA induced hemolysis.
AI 2:That's the theory. The hemolysis gobbles up nitric oxide, No, which the blood vessels need to stay relaxed. Take away the No and you risk severe diffuse spasm.
AI 1:Wow. So that's the first time that connection's been published, linking the hemolysis from PFA directly to this kind of delayed dangerous coronary event.
AI 2:Right. And it makes you think maybe for extensive PFA cases, we should be considering things like prophylactic nitrates. Needs more study, but it's a serious thought.
AI 1:Okay. So we have this picture. PFA is efficient, no doubt, but it comes with this measurable systemic cost and these rare but devastating risks.
AI 2:It's a complex balance.
AI 1:And that very complexity, the need for such precision to avoid collateral damage, that actually leads us perfectly into the next topic, AI.
AI 2:Right. Because if the procedure is this delicate, we need smarter tools to guide it.
AI 1:Enter AI. What was unveiled at Heart Rhythm twenty twenty five?
AI 2:The big one was the Deep Prism model. And this isn't just like workflow optimization AI. No. This is AI using deep learning to analyze intracardiac signals in real time during the procedure.
AI 1:To do what specifically?
AI 2:To predict the exact spots, the termination sites, for persistent AF based on data from about 110 patients.
AI 1:Okay, so AI is moving from the background optimizing scheduling or something right into the heart of the decision making during the ablation itself.
AI 2:Exactly. It's anchoring the intervention and the results were pretty impressive.
AI 1:What did they find?
AI 2:The model helped achieve forty percent acute termination of the AF right there on the table.
AI 1:Percent acute success is significant.
AI 2:It is. And maybe even more importantly, up to seventy percent of those patients were still arrhythmia free. Two years later,
AI 1:seventy percent at two years is a really strong outcome for persistent AF.
AI 2:It really is. It suggests AI can be like a copilot guiding the operator to the most critical spots, maximizing the effectiveness, and hopefully minimizing that collateral damage we were just talking about.
AI 1:So let's try and wrap this up. What's the takeaway for you listening?
AI 2:Well, PFA clearly offers big advantages in efficiency. But we have to acknowledge this data, like from Nemesis. There's a real quantifiable systemic burden hitting the blood, kidneys, the heart muscle itself.
AI 1:While at the same time the technology driving the procedure is rapidly evolving from being helpful to being potentially essential for doing it safely and effectively.
AI 2:Right. It's a dual reality unfolding.
AI 1:So maybe a final thought to leave people with.
AI 2:Okay. Here's something to mull over. We now have evidence of these medium to large silent strokes plus this clear systemic burden from PFA. How do you as a clinician balance the known efficiency of PFA against the need for potentially more comprehensive, maybe even delayed surveillance after the procedure?
AI 1:That's the tough question, isn't it? How much monitoring is enough given these new findings?
AI 2:Exactly. That's the conversation we need to be having as this technology matures.
Dr Niraj Sharma:Thank you for listening to this inaugural episode of EP Edge podcast. What you just heard was more than just a newsletter in audio form. It is the start of a new way of sharing and shaping conversation around electrophysiology. Next episode from June 2025, explores VT ablation and therapy and determines whether the current guidelines are out of date and possibly need revision. I would love to make this podcast a two way conversation.
Dr Niraj Sharma:You can email me your questions, comments, or current topic suggestions to ephcastgmail dot com or connect with me on LinkedIn. If you found this valuable, please subscribe, share and help grow the EP Edge community. I'm Doctor. Niraj Sharma and together we're going to stay on the edge of electrophysiology. Thank you and bye for now.