Top Heart Rhythm News of 2024

As in years past, treatment options for patients with atrial fibrillation garnered much of the spotlight in 2024 in terms of the major developments in the field of heart rhythm disorders.

Pulsed-field ablation had a big year following the first US Food and Drug Administration approval for a PFA (30 Across) system at the end of 2023—that was for the PulseSelect system (Medtronic). That was followed by an approval for Farapulse (Boston Scientific) in January and, more recently, green lights for Varipulse (Johnson & Johnson MedTech) and the Affera mapping and ablation system with Sphere-9 catheter (Medtronic), which can deliver both pulsed-field and radiofrequency energy.

Though electrophysiologists are excited about PFA as a way to perform shorter, safer ablation procedures, there are still some unknowns, including questions about the long-term durability of the ablations and about the occurrence of rare but serious complications like coronary spasm and hemolysis leading to acute renal failure.

Kalyanam Shivkumar, MD, PhD (UCLA Health, Los Angeles, CA), editor-in-chief of JACC: Clinical Electrophysiology, said PFA “has taken the world by storm” following the US regulatory approvals and amid mounting evidence bolstering its efficacy. “This is dramatically impacting workflow,” he told TCTMD.

Some referring physicians may still be skeptical about the impact of catheter ablation for atrial fibrillation (AF; 9 Down), and there has been an ongoing discussion about whether a sham-controlled trial testing the procedure would be feasible or even necessary. The feasibility issue was addressed by the SHAM-PVI trial, which was presented at the European Society of Cardiology Congress in September and published simultaneously online in JAMA. Compared with a sham procedure, pulmonary vein isolation (PVI; 30 Down) using cryoablation reduced AF burden and improved arrhythmia-related symptoms and quality of life.

Another newsworthy trial for AF patients was OPTION (55 Across), which was presented at the American Heart Association Scientific Sessions and published in the New England Journal of Medicine in November. The results show that when added to catheter ablation, left atrial appendage occlusion (LAAO) with the Watchman FLX device (Boston Scientific) lessened bleeding and provided noninferior efficacy compared with direct oral anticoagulants, although some commentators raised questions about the endpoints used in the trial.

“I think it will impact practice, and I’m fully anticipating that we’ll see its full effect in the coming years,” Shivkumar said.

Also in the realm of AF, the EPIC-CAD trial (EPICCAD; 43 Across), presented at ESC 2024 and published in NEJM, demonstrated that for patients with high-risk AF and stable coronary artery disease, the rate of net adverse clinical events at 1 year was significantly lower among those treated with edoxaban (Savaysa; Daiichi Sankyo) alone versus edoxaban plus antiplatelet therapy, mostly due to a lower risk of bleeding.

At the same conference, attendees heard about updated European AF guidelines, which introduce a new pathway called AF-CARE, incorporating comorbidity and risk factor management (C), avoidance of stroke and thromboembolism (A), reduction of symptoms by rate and rhythm control (R), and evaluation and dynamic assessment (E). And earlier in the year, multiple heart rhythm societies from around the world issued a new expert consensus statement on catheter and surgical ablation of AF.

Beyond AF, Shivkumar pointed to the continued emergence of physiologic or conduction-system pacing, including left bundle branch area pacing, as major news in 2024. “It’s becoming very prevalent and has had a big impact in clinical care,” he said.

There has also been growing attention on artificial intelligence-aided diagnosis, “an active area of a lot of excitement and ongoing research,” Shivkumar said.

More data have been published, too, on prevention of arrhythmias, he said, highlighting as an example a study published in JACC: EP earlier this year that showed quitting smoking was associated with a lower risk of developing AF.

Moving into 2025, Shivkumar said the field will be seeing more data on the use of implantable and wearable devices. In addition, he said, “we will be looking at the expanded use of left atrial appendage occlusion devices. And we’re likely to be seeing more data on catheter ablation of ventricular tachycardia and potentially the use of things like pulsed-field ablation in substrates beyond atrial fibrillation. We probably will be seeing more data of its use in ventricular arrhythmias.”