Aims: Although guidelines for the management of atrial fibrillation (AF) are regularly published, many controversial issues remain, limiting their implementation. We aim to describe current clinical practice among European Heart Rhythm Association (EHRA) community according to last guidelines. Methods and results: A 30 multiple-choice questionnaire covering the most controversial topics related to AF management was distributed through the EHRA Research Network, National Societies, and social media between January and February 2023. One hundred and eighty-one physicians responded the survey, 61% from university hospitals. Atrial fibrillation screening in high-risk patients is regularly performed by 57%. Only 42% has access to at least one programme aiming at diagnosing/managing comorbidities and lifestyle modifications, with marked heterogeneity between countries. Direct oral anticoagulants are the preferred antithrombotic (97%). Rhythm control is the preferred strategy in most AF phenotypes: symptomatic vs. asymptomatic paroxysmal AF (97% vs. 77%), low vs. high risk for recurrence persistent AF (90% vs. 72%), and permanent AF (20%). I-C drugs and amiodarone are preferred while dronedarone and sotalol barely used. Ablation is the first-line therapy for symptomatic paroxysmal AF (69%) and persistent AF with markers of atrial disease (57%) and is performed independently of symptoms by 15%. In persistent AF, 68% performs only pulmonary vein isolation and 32% also additional lesions. Conclusion: There is marked heterogeneity in AF management and limited accordance to last guidelines in the EHRA community. Most of the discrepancies are related to the main controversial issues, such as those related to AF screening, management of comorbidities, pharmacological treatment, and ablation strategy.

Aims: Pulsed field ablation (PFA) has rapidly emerged as a non-thermal ablation technology for pulmonary vein isolation (PVI), with an unprecedented adoption across Europe. The aim of this survey was to characterize current practice patterns. Methods and results: The European Heart Rhythm Association (EHRA) Scientific Initiatives Committee designed a 30-item questionnaire addressing temporal adoption of PFA, pre-, intra-, and post-procedural workflows, and future perspectives. The survey was distributed between April and June 2025. A total of 216 responses were obtained from 43 countries. At the time of the survey, 23% of respondents had not yet initiated a PFA programme. Overall, PFA is now used in half (49%) of first atrial fibrillation (AF) ablation procedures. Adoption was significantly higher in high-volume centres and ‘Western European’ countries. The primary driver for adoption was time efficiency (60%). Intra-procedural workflows showed marked heterogeneity: approximately half of the operators relied exclusively on fluoroscopy without any intra-procedural imaging/mapping. Additional ablation lesions beyond PVI were common, with one-third employing standardized PVI+ protocols in persistent AF, most frequently posterior wall isolation. General anaesthesia and deep sedation were used in equal proportions. Conclusion: This EHRA survey demonstrates both rapid implementation and significant heterogeneity in PFA use across Europe. Standardized protocols and prospective studies are needed to define best practices.

Aims: Arrhythmia-induced cardiomyopathy (AiCM) represents a subtype of acute heart failure (HF) in the context of sustained arrhythmia. Clear definitions and management recommendations for AiCM are lacking. The European Heart Rhythm Association Scientific Initiatives Committee (EHRA SIC) conducted a survey to explore the current definitions and management of patients with AiCM among European and non-European electrophysiologists. Methods and results: A 25-item online questionnaire was developed and distributed among EP specialists on the EHRA SIC website and on social media between 4 September and 5 October 2023. Of the 206 respondents, 16% were female and 61% were between 30 and 49 years old. Most of the respondents were EP specialists (81%) working at university hospitals (47%). While most participants (67%) agreed that AiCM should be defined as a left ventricular ejection fraction (LVEF) impairment after new onset of an arrhythmia, only 35% identified a specific LVEF drop to diagnose AiCM with a wide range of values (5–20% LVEF drop). Most respondents considered all available therapies: catheter ablation (93%), electrical cardioversion (83%), antiarrhythmic drugs (76%), and adjuvant HF treatment (76%). A total of 83% of respondents indicated that adjuvant HF treatment should be started at first HF diagnosis prior to antiarrhythmic treatment, and 84% agreed it should be stopped within six months after LVEF normalization. Responses for the optimal time point for the first LVEF reassessment during follow-up varied markedly (1 day–6 months after antiarrhythmic treatment). Conclusion: This EHRA Survey reveals varying practices regarding AiCM among physicians, highlighting a lack of consensus and heterogenous care of these patients.

Aims: Lifestyle and risk factor modification (LRFM) forms a central pillar in the management of atrial fibrillation (AF). This European Heart Rhythm Association (EHRA) survey aims to assess current clinical practice regarding LRFM across EHRA countries. Methods and results: A 31-item questionnaire was developed and distributed amongst healthcare professionals via the EHRA and social media, between 23 September and 21 October 2024. Of 258 respondents from 28 countries, 39.9% reported that their healthcare system is badly or very badly designed to deliver meaningful LRFM. Risk factors that respondents felt least confident managing included psychological distress (42.2% of respondents not confident), sleep-disordered breathing (33.8%), and obesity (22.4%). Respondents estimated that 70% of patients with AF at their institution may benefit from exercise-based cardiac rehabilitation but that only 10% are referred for this. The most important barrier to cardiac rehabilitation in AF was identified as local programmes not accepting patients with AF only (42.1% of respondents). Despite 37.7% of respondents using a body mass index cut-off when deciding on catheter ablation suitability (with a mean cut-off of 36.7 ± 5.4 kg/m2), only 23.5% of patients with obesity are referred for formal dietary advice. Lack of patient motivation or engagement was identified as the most important barrier to weight loss (41.3% of respondents). Moreover, 89.6% of respondents routinely assess their patient's alcohol intake, whilst only 23.9% systemically assess for psychological distress and 16.5% for sleep-disordered breathing. Conclusion: Delivering comprehensive LRFM in AF poses significant challenges. Improvements to healthcare infrastructures are required to successfully implement meaningful LRFM.

Aims: Simulator training has been recently introduced in electrophysiology (EP) programmes in order to improve catheter manipulation skills without complication risks. The aim of this study is to survey the current use of EP simulators and the perceived need for these tools in clinical training and practice. Methods and results: A 20-item online questionnaire developed by the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) in collaboration with EHRA Digital Committee was disseminated through the EHRA Scientific Research Network members, national EP groups, and social media platforms. Seventy-four respondents from 22 countries (73% males; 50% under 40 years old) completed the survey. Despite being perceived as useful among EP professionals (81%), EP simulators are rarely a part of the institutional cardiology training programme (20%) and only 18% of the respondents have an EP simulator at their institution. When available, simulators are mainly used in EP to train transseptal puncture, ablation, and mapping, followed by device implantation (cardiac resynchronization therapy [CRT], leadless, and conduction system pacing [CSP]). Almost all respondents (96%) believe that simulator programmes should be a part of the routine institutional EP training, hopefully developed by EHRA, in order to improve the efficacy and safety of EP procedures and in particular CSP 58%, CRT 42%, leadless pacing 38%, or complex arrhythmia ablations (VT 58%, PVI 45%, and PVC 42%). Conclusion: This current EHRA survey identified a perceived need but a lack of institutional simulator programme access for electrophysiologists who could benefit from it in order to speed up the learning curve process and reduce complications of complex EP procedures.

Aims: Ablation modalities differ in their mechanisms of action, tissue specificity, and collateral effects—particularly on the cardiac autonomic nervous system. This study aimed to compare the autonomic effects of pulsed field ablation (PFA) vs. thermal ablation (TA) in patients with atrial fibrillation (AF) through a pooled analysis. Methods and results: A systematic search of PubMed and Embase was conducted through 5 April 2025, to identify comparative studies. The primary outcome was increase in heart rate (IHR) after ablation, and the secondary outcome was increase in serum S100B (IS100B), a marker of neural injury. Eight studies involving 1007 AF patients were included (mean age: 63.39 ± 10.75 years; 36.3% female; maximum follow-up: 12 months). Baseline characteristics, including the use of antiarrhythmic drugs, were similar between the PFA and TA groups. Pooled analysis showed that PFA was associated with a significantly lower IHR compared to TA (PFA: 4.41 ± 8.86 bpm vs. TA: 10.81 ± 10.46 bpm; P < 0.00001). This difference persisted at midterm (3–6 months) and long-term (12 months) follow-up and remained consistent across age, sex, and different TA modalities (cryoballoon vs. radiofrequency). Correspondingly, the IS100B was significantly less pronounced after PFA (PFA: 33.27 ± 9.46 pg/mL vs. TA: 97.53 ± 31.88 pg/mL; P < 0.00001). Conclusion: PFA-based pulmonary vein isolation in patients with AF results in a smaller post-procedural IHR and less S100B release, suggesting reduced neural damage and less disruption of the autonomic nervous system compared to TA. These effects are sustained through mid- to long-term follow-up and may have potential implications for patient selection and individualized ablation strategies.