EHRA 2026: Defining the Next Era of Arrhythmia Care

Which late-breaking trials presented at EHRA 2026 do you believe will most immediately influence clinical decision-making in arrhythmia management?

Selecting the best submissions this year was a formidable task. From 105 high-quality entries, we narrowed our selection down to the top 20. Highlights include two major randomized trials evaluating conduction system pacing (CSP) in heart failure patients. While one trial demonstrated the superiority of CSP over biventricular pacing for cardiac resynchronization therapy (CRT), the other remained neutral, offering a fascinating opportunity to analyze the underlying reasons for these differing outcomes.¹ In the ablation field, we saw critical comparisons between cryo/radiofrequency and pulsed field ablation (PFA). Lastly, pharmacological research remains a cornerstone of our congress, notably with a trial comparing flecainide versus amiodarone in coronary artery disease patients without residual ischemia.²

How have the latest advances in catheter ablation technologies and strategies shifted your approach to treating complex atrial fibrillation cases?

Currently, we are navigating significant pressure to increase procedural volumes while managing an aging and increasingly frail patient population – a reflection of atrial fibrillation (AF)’s rising prevalence. As ablation outcomes continue to improve, patient awareness has grown, leading to a surge in referrals. While paroxysmal AF has become a relatively streamlined procedure, the adoption of PFA has further optimized our workflow, allowing us to treat patients more safely and efficiently.

However, for more complex cases, specifically persistent and long-standing persistent AF, pulmonary vein isolation (PVI) alone is often insufficient. While a global consensus on extra-PVI targets remains elusive, our approach involves creating linear lesions. The emergence of hybrid technologies, combining radiofrequency (RF) and PFA, is enabling us to perform these complex ablations with unprecedented speed and precision.³ We are truly living in an exciting era for electrophysiology.

Were there any notable updates in device therapy such as leadless pacing or implantable cardioverter defibrillator (ICD) innovations that could change current practice standards?

In my view, leadless pacing is undergoing a steady, albeit deliberate, evolution. While dual-chamber leadless systems are now a reality, widespread adoption remains on the horizon, largely due to the competing clinical interest in CSP. Although there are ongoing initiatives to integrate these two modalities, we are still in the early stages. One significant historical limitation of CSP has been its application in patients requiring an ICD, as we lacked a single lead capable of both physiological pacing and defibrillation. However, new developments in lead design are now addressing this gap, marking this as a rapidly advancing frontier in cardiac rhythm management.

What emerging data on risk stratification and prevention of sudden cardiac death stood out to you, particularly for high-risk patient populations?

The landscape of ICD therapy is undergoing a profound transformation. While classic trials established the mortality benefits of ICDs in patients with ischemic and non-ischemic left ventricular dysfunction, the landscape has changed. The remarkable efficacy of modern heart failure therapies has significantly reduced the baseline incidence of sudden cardiac death (SCD), leading some to question the incremental benefit of devices.⁴ Conversely, we are seeing a shift toward a more personalized approach. Emerging data suggest that even in patients with higher left ventricular ejection fraction, specific markers—such as late gadolinium enhancement on magnetic resonance imaging and high-risk genetic profiles—can identify those who still derive significant benefit from an ICD.

Looking ahead, which research gaps or unanswered questions highlighted at ERA 2026 should be priorities for future clinical investigations?

We are currently in a steep learning phase with these emerging technologies. While PFA has revolutionized the field, we are still arguably in its first generation. The next frontier, such as nanosecond PFA, promises to minimize muscular recruitment, further simplifying procedures and potentially allowing for broader use of conscious sedation. Beyond the lab, we must refine our post-ablation antithrombotic strategies. Recent data suggest that in the absence of recurrences, discontinuing anticoagulation may be safe and significantly reduces bleeding risk. Lastly, we must not overlook pharmacotherapy. Given the sheer volume of AF patients and the complexities of peri-procedural management, the emergency room setting, and device-detected arrhythmias, the continued development of antiarrhythmic drugs remains a clinical necessity.