Genetic testing for inherited arrhythmia syndromes and cardiomyopathies (September 2024)
Indications and clinical impact of genetic testing for cardiac diseases have increased significantly over the past years. The aim of this physician-based European Heart Rhythm Association (EHRA) survey was to assess current clinical practice and access to genetic testing for cardiac diseases across European Society of Cardiology countries and to evaluate adherence to the 2022 EHRA/HRS/APHRS/LAHRS Expert Consensus Statement on genetic testing.
This survey highlights a significant heterogeneity of genetic testing access and provision and issues attributable to the availability of dedicated unit/genetic laboratory and reimbursement. However, adequate adherence to indications in the current recommendations for genetic testing in patients with cardiac diseases was observed.
The publication is available as a PDF or as an article in EP Europace.
Cardioneuroablation for vasovagal syncope (May 2024)
Cardioneuroablation (CNA) is a recently introduced catheter-based therapy for vasovagal syncope (VVS), involving the modulation of the cardiac autonomic nervous system. Over the past decade, the body of evidence supporting CNA has consistently grown, sparking increased interest, and leading to broader adoption of this novel therapy for VVS treatment. However, several knowledge gaps persist, particularly concerning clinical indications, methodology, and long-term outcomes.
The aim of this survey is to provide a comprehensive overview of the daily utilization of CNA in Europe.
The publication is available as a PDF or as an article in EP Europace.
Definition and management of arrhythmia-induced cardiomyopathy (May 2024)
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.
This EHRA Survey reveals varying practices regarding AiCM among physicians, highlighting a lack of consensus and heterogenous care of these patients.
The publication is available as a PDF or as an article in EP Europace.
STereotactic Arrhythmia Radioablation and its implications for modern cardiac ElectroPhysiology: results of an EHRA Survey (May 2024)
Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown.
The objective of this survey was to assess the current role, barriers to application and expected future role of STAR.
The online survey consisted of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted.
The publication is available as a PDF or as an article in EP Europace.
Management of ventricular tachycardias: insights on centre settings, procedural workflow, endpoints, and implementation of guidelines (February 2024)
Ventricular tachycardia (VT), and its occurrence, is still one of the main reasons for sudden cardiac death and, therefore, for increased mortality and morbidity foremost in patients with structural heart. Catheter ablation has become a safe and effective treatment option in patients with recurrent VT. Previous and current guidelines provide guidance on indication for VT ablation and risk assessment and evaluation of underlying disease. However, no uniform recommendation is provided regarding procedural strategies, timing of ablation, and centre setting. Therefore, these specifics seem to differ largely, and recent data are sparse. This physician-based EHRA survey aims to deliver insights on not only infrastructural settings but also procedural specifics, applied technologies, ablation strategies, and procedural endpoints. Therefore, these findings might deliver a real-world scenario of VT management and potentially are of guidance for other centres.
The publication is available as a PDF or as an article in EP Europace.
Utilisation of and perceived need for simulators in clinical electrophysiology (February 2024)
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 was to survey the current use of EP simulators and the perceived need for these tools in clinical training and practice.
This 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.
The publication is available as a PDF or as an article in EP Europace.
Current management of atrial fibrillation in routine practice according to the last ESC guidelines (January 2024)
Although guidelines for the management of atrial fibrillation (AF) are regularly published, many controversial issues remain, limiting their implementation. This survey aims to describe current clinical practice among the EHRA community according to last guidelines.
This survey shows 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.
The publication is available as a PDF or as an article in EP Europace.
Prevention and treatment of pericardial tamponade in the electrophysiology laboratory (January 2024)
Catheter ablation is an established treatment option for various types of arrhythmias and, in general, has a high success rate and an excellent safety profile. However, despite increasing experience and improved ablation strategies and technologies, complications can occur and can be potentially life-threatening. Pericardial tamponade (PT) is the most frequent severe complication during electrophysiology (EP)procedures and requires immediate, co-ordinated, and effective treatment. However, the treatment of PT is not standardized and various aspects are still under debate.
Therefore, we conducted a survey evaluating the infrastructure, safety precautions, and treatment strategies in the setting of PT in European and non-European EP centres.
The publication is available as a PDF or as an article in EP Europace.
Prevention of venous thromboembolism in right heart–sided electrophysiological procedures (December 2023)
Limited data are available regarding venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), following right-sided ablations and electrophysiological (EP) studies. Compared to left-sided procedures, no guidelines on antithrombotic management strategies for the prevention of DVT and PE are available. The main purpose of the present survey is to report the current management of right-sided EP procedures, focusing on anticoagulation and prevention of VTE.
The publication is available as a PDF or as an article in EP Europace.
Length of hospital stay for elective electrophysiological procedures (October 2023)
Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day-case procedures. The coronavirus (COVID-19) pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era.
The publication is available as a PDF or as an article in EP Europace.
Electrophysiology fellowship experience and requirements (September 2023)
The field of cardiac electrophysiology (EP) is a rapidly growing subspecialty in cardiology, which requires understanding of mechanisms of cardiac arrhythmias to become familiar with different treatment strategies. It includes a wide range of conventional and complex catheter ablation procedures for various cardiac arrhythmias and the implantation and follow-up of cardiac implantable electronic devices.
The Accreditation Committee of the European Heart Rhythm Association (EHRA) has previously introduced specific curricula in 2009, defining requirements for both training centres and trainees. However, a recent EHRA survey conducted by the e-Communication and Digital Committee and the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) showed that considerable heterogeneity exists with respect to certification processes and standardized fellowship programmes during the EP training across European Society of Cardiology (ESC) member countries.
The publication is available as a PDF or as an article in EP Europace.
Occupational radiation exposure of electrophysiology staff with reproductive potential and during pregnancy (July 2023)
Electrophysiology (EP) is a growing cardiology field, attracting more young professionals. Concerns about radiation exposure and its impact on reproductive capacity and pregnancy can discourage EP career choices. This survey (April to June 2022; 252 participants from 50 countries) investigates awareness and concerns about radiation's effects on reproductive capacity and pregnancy, safety measures in EP labs, and guideline adherence. Most participants share concerns about radiation's impact on reproduction and offspring, regardless of gender. Only 37.9% knew the EHRA 2017 consensus document. Implementation of pregnancy and radiation exposure policies remains heterogeneous despite international recommendations. Zero-fluoroscopy is the preferred approach for safety during pregnancy in the EP lab.
The publication is available as a PDF or as an article in EP Europace.
Diagnostic and therapeutic pathways for the malignant left atrial appendage (July 2023)
Left atrial appendage (LAA) is the predominant source for thrombus formation in patients with atrial fibrillation (AF). There are AF patients who suffer stroke or systemic embolism (SSE) despite taking oral anticoagulants or in whom LAA thrombus formation is diagnosed via standard imaging modalities and develops despite consistent oral anticoagulation. Malignant left atrial appendage can be coin termed/diagnosed in these clinical scenarios.
The optimal treatment/prevention strategy to reduce SSE risk in such patients is unknown.
Therefore, the aim of this physician-based survey is to assess the diagnostic and therapeutic pathways that are currently practiced in this not-so-rare scenario. The results might shed light on physicians'/centres' treatment choices in this area of uncertainty, uncovered by guidelines, and serve as a reference for a position/consensus paper by EHRA.
The publication is available as a PDF or as an article in EP Europace.
Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation (December 2022)
Catheter ablation (CA) of atrial fibrillation (AF) is the therapy of choice for maintenance of sinus rhythm in patients with symptomatic AF. The scope of this European Heart Rhythm Association (EHRA) survey was to report the current clinical practice regarding the management of patients undergoing AF ablation and physician’s adherence to guidelines. From the 258 physicians participating in the survey, 42% would routinely perform AF ablation as first-line therapy in patients with paroxysmal and 9% in patients with persistent AF. Furthermore, 71% of the physicians would consider ablation as first-line therapy in patients with symptomatic AF and left ventricular ejection fraction <35%. Only 14% of respondents manage cardiovascular risk factors in patients referred for CA using a dedicated AF risk factor management program. Radiofrequency CA is the preferred technology for first-time AF, followed by cryo-balloon CA.
The publication is available as a PDF or as an article in EP Europace.
Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation (November 2022)
Atrial fibrillation (AF) is a major challenge for the healthcare field. Pulmonary vein isolation is the most effective treatment for the maintenance of sinus rhythm. However, clinical endpoints for the procedure vary significantly among studies. There is no consensus on the definition of recurrence and no clear roadmap on how to deal with recurrences after a failed ablation. In order to show how clinicians currently approach this knowledge gap the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee supported an online survey, disseminated via social media and EHRA newsletters, regarding rhythm monitoring, definitions of a successful ablation, clinical practices after a failed AF ablation, and the continuance of anticoagulation. A total of 107 replies were collected across Europe. Most respondents (82%) perform routine monitoring for AF recurrences after ablation, with 51% of them preferring a long-term monitoring strategy. Cost was reported to have an impact on the choice of monitoring strategy. Self-screening was recommended by most (71%) of the respondents. The combination of absence of symptoms and recorded AF was the definition of success for most (83%) of the respondents. Cessation of anticoagulation after ablation was an option mostly for patients with paroxysmal AF and a low CHA2DS2-VASc score. The majority of physicians perform routine monitoring after AF ablation. For most physicians, the combination of the absence of symptoms and electrocardiographic endpoints defines a successful result after AF ablation.
The publication is available as a PDF or as an article in EP Europace.
Conduction system pacing in everyday clinical practice (October 2022)
This survey aimed to provide a snapshot of current practice in conduction system pacing (CSP) across Europe as there is increased interest in this treatment modality over the last few years as well as its inclusion in the current ESC guidelines.
An online questionnaire was sent to physicians participating in the European Heart Rhythm Association (EHRA) research network as well as to national societies and over social media. Data on previous experience with CSP, current indications, preferred tools, unmet needs, and perceptions for the future are reported and discussed.
Over half of respondents had previous experience with either His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), indicating high adoption rates (but most of the data reflected practice in university centres). Among those who did not adopt CSP, the main reason (75% of respondents) was lack of training. Only a minority (4.4%) believed that CSP is not useful. In patients with bradycardia indication, CSP was the preferred pacing modality. In patients with an indication for cardiac resynchronization therapy with left bundle branch block, biventricular pacing remains the preferred strategy. The majority of CSP implantations are performed using lumenless leads, but stylet-driven leads are also used, mainly for LBBAP. Respondents anticipate that CSP (mainly LBBAP) will predominate over conventional right ventricular pacing in the future.
This survey indicates that CSP has gained mainstream clinical practice in many centres. There is likely to be continued uptake of CSP (predominantly of LBBAP) as familiarity and expertise with implantation grows, new tools are developed to facilitate the procedure, and more data are published to confirm the safety and effectiveness of this treatment modality.
The publication is available as a PDF or as an article in EP Europace.
Contemporary management of ventricular electrical storm in Europe (October 2022)
Electrical storm (ES) is a predictor of mortality, and its treatment is challenging. Moreover, not all potential therapeutic strategies are available in all hospitals, and a standardised approach among European centres is lacking. The aim of this European Heart Rhythm Association (EHRA) survey was to assess the current management of patients with ES both in the acute and post-acute phases in 102 different European centres. A 20-item online questionnaire was sent out to the EHRA Research Network Centres. The median number of patients with ES treated annually per centre is 10 (IQR 5–15). The possibility of using autonomic modulation (e.g. percutaneous stellate ganglion block or thoracic epidural anaesthesia) for the acute ES treatment is available in only 29.3% of the centres. Moreover, although over 80% of centres perform ventricular tachycardia ablation, this procedure is available 24/7 in only 16.5% of the hospitals.
There is a significant heterogeneity among centres regarding the availability of antiarrhythmic drugs (AADs) and their use before deciding to proceed with a non-AAD strategy; specifically, 4.4% of centres use only one drug, 33.3% use two drugs, and 12.2% >two drugs, while about 50% of the centres decide based on individual patient’s characteristics. Regarding the type of AADs used for the acute and post-acute management of ES patients, important variability is reported depending upon the underlying heart disease. Most patients considered for percutaneous ablation have structural heart disease. Only 46% of centres refer patients to psychological counselling after ES.
The publication is available as a PDF or as an article in EP Europace.
Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias (August 2022)
Digital devices are increasingly used in cardiology for assessing cardiac rhythm and detecting arrhythmias, especially atrial fibrillation (AF), and the European Heart Rhythm Association (EHRA) is deeply involved in all the aspects of evaluation, clinical use and implementation of these devices. The Section on Health Economics Committee of EHRA in collaboration with the Committees on Digital Health, Communication and Scientific Initiatives promoted a European survey to evaluate the expectations and opinions of healthcare professionals in Europe on reimbursement policies for the use of digital devices (including wearables) in AF and other arrhythmias.
The survey clearly highlighted that digital devices, including wearables, are increasingly and widely used for assessing cardiac rhythm and detecting AF, but a definition of reimbursement policies for physicians’ consultations is needed, also when the use of these tools is consumer-initiated. A strict collaboration is needed between policymakers, scientific associations, and patient associations for guiding the appropriate use of digital devices and the organization of care pathways for a referral.
The publication is available as a PDF or as an article in EP Europace.
Current practices and expectations to reduce environmental impact of electrophysiology catheters: results from an EHRA/LIRYC European physician survey (August 2022)
Addressing the environmental impact of healthcare has become a priority and technology-heavy specialties such as cardiac EP represent important targets for sustainable practices. The EHRA Scientific Initiatives Committee collaborated with the LYRIC Institute to investigate the practice and expectations in European centres on the environmental sustainability of EP catheters.
62% of physicians demonstrate motivation towards sustainable EP practices. More than half of catheters and more than two-thirds of packaging are currently discarded directly after use. Catheter re-use after internal sterilization or external reprocessing occurs in a minority of cases (one fifth or less, depending on catheter type). Nearly two-thirds of physicians consider reusing as the most effective strategy for more sustainable practice. More than half of the physicians would favor sustainable mapping and ablation catheters, if performance were preserved. Lack of engagement from host institutions was the most commonly cited barrier to sustainable practices (59%). Up to half of the polled physicians also cited complexity of the process and challenges to behavioral change as barriers to sustainable practices. In terms of potential solutions, regulatory changes (31%), education (19%) and specific after-use recommendations by companies (19%) featured prominently.
The publication is available as a PDF or as an article in EP Europace.
The blanking period after atrial fibrillation ablation: a European Heart Rhythm Association survey on contemporary definition and management (August 2022)
The Scientific Initiative Committee (SIC) of the European Heart Rhythm Association (EHRA) conducted a survey among clinical and interventional electrophysiologists to spread some light on the blanking period (BP). This is a period of time following an atrial fibrillation ablation where recurrences are not considered a treatment failure since delayed cure was thought to be common. However, recent data questioned the benign nature of early recurrences of atrial tachyarrhythmias (ERATs) and the traditional duration of the BP (90 days). 436 respondents took part to the survey, indicating that ERATs are a common observation (25% of patients). ERATs are perceived to be associated to late recurrences in a median of 50% of patients. The BP is usually respected with most ERAT treated conservatively, but early re-ablation during the BP is performed in patients with multiple episodes of ERATs and in those with organised atrial tachyarrhythmias
The publication is available as a PDF or as an article in EP Europace.
Management of conduction disorders after transcatheter aortic valve implantation: results of an EHRA survey (March 2022)
Conduction disorders such as left bundle branch block (LBBB) are common after transcatheter aortic valve implantation (TAVI). A standardised management protocol for advanced conduction disorders after TAVI was available in 63% of participating centers. Duration of telemetry in patients with new-onset LBBB varied, with a 48-hour period the most frequently chosen but almost half monitoring for at least 72 hours. In patients undergoing EP study due to new-onset LBBB, the HV interval cut-off leading to PM implantation was heterogenous among European centres, although an HV >75ms was the most common. This survey revealed a large variation in the management of conduction disorders after TAVI.
The publication is available as a PDF or as an article in EP Europace.
Contemporary clinical management of monomorphic idiopathic premature ventricular contractions: results of the European Heart Rhythm Association survey (January 2022)
The most common symptom in patients with idiopathic monomorphic PVCs was palpitations, according to the majority of responses (87%). Blood cell count, renal function with electrolytes levels and thyroid function are the most common laboratory items chosen by clinicians involved in the survey, but there was also some interest towards CRP and NTproBNP.
PVC burden and the presence of PVC-induced cardiomyopathy are the most important factors for treatment initiation; the most-chosen burden cut-off was 10% calculated in a 24-hour Holter ECG. There was good agreement among the participants of the survey on the fact that cardiac electrophysiologists should be involved in the treatment of idiopathic PVCs, especially in the presence of PVC-induced cardiomyopathy, anti-arrhythmic drug failure, high burden of PVCs (≥ 15% on 24-hour Holter monitoring). Catheter ablation is considered an important treatment option by the majority of respondents (99%).
The publication is available as a PDF or as an article in EP Europace.
The use of social media for professional purposes by healthcare professionals: the #intEHRAct survey (October 2021)
Nowadays, social media (SoMe) represent a medium of communication in everyday life and has gained importance for professional use among clinicians. The #intEHRAct survey aimed to describe the use of SoMe by the healthcare community. The EHRA e-Communication Committee and the Scientific Initiatives Committee prepared a questionnaire and collected replies from 285 responders from 35 countries. Most respondents declared to use SoMe as passive users while 38.3% and 19.0% declared to share content on a non-daily and daily basis, respectively.
The respondents estimated they spent a median of five hours per week on SoMe. The most widely used SoMe was LinkedIn, but the use of each platform was heterogeneous between countries. The chance of being updated on recent publications was the advantage proposed more often while the loss of personal contact was the most frequent drawback. The results of this survey encourage scientific societies, journals, and authors to enhance the quality, reach and impact of scientific content provided through SoMe.
The publication is available as a PDF or as an article in EP Europace.
The use of remote monitoring of cardiac implantable devices during the COVID-19 pandemic: an EHRA physician survey (August 2021)
The influence of the COVID-19 pandemic on remote monitoring of cardiac implantable devices is unclear. This EHRA survey aimed to assess the influence of the COVID-19 pandemic on the use of remote monitoring of cardiac implantable devices among EHRA Members and how it changed the current practice. The online survey included 27 questions, focusing on the use of remote monitoring before and during the pandemic, frequency of in-office visits, data filtering, reasons for initiating in-person visits, underutilisation and reimbursement of remote monitoring during the COVID-19 pandemic. A total number of 160 participants from 28 countries completed the survey.
A significant increase in the use of remote monitoring in patients with pacemakers and implantable loop recorders was observed, compared to the pre-pandemic period. The use of remote monitoring with implantable cardioverter-defibrillators and cardiac resynchronisation defibrillators did not significantly change during this period, while there was a trend towards higher utilisation of remote monitoring for cardiac resynchronisation therapy-pacemaker devices during the pandemic. The results of this survey highlight the impact of the COVID-19 pandemic on the use of remote monitoring of cardiac implantable devices.
The publication is available as a PDF or as an article in EP Europace.
Investigation on sudden unexpected death in the young (SUDY) in Europe: results of the European Heart Rhythm Association survey (August 2021)
The Scientific Initiative Committee and European Cardiac arrhythmia Genetics (ECGen) focus group of EHRA have collaborated to undertake a survey of the pathological and genetic assessment of cases of sudden death in the young and the evaluation of their families. Participants were surveyed from across Europe and were members of the EHRA research network and/or the European Reference Network GUARD-Heart. The findings suggest heterogeneity of provision of autopsy and post-mortem genetic testing in decedents, and of clinical and psychological support services for relatives. A need for better adherence to current guidelines was identified. The survey provides an opportunity for European centres to reassess their services and to lobby for better autopsy provision.
The publication is available as a PDF or as an article in EP Europace
Worldwide sedation strategies for atrial fibrillation ablation: current status and evolution over the last decade (July 2021)
Catheter ablation for atrial fibrillation has become one of the most common procedures in the electrophysiology lab with rapidly increasing volumes. Peri-procedural anaesthesia for AF ablation varies between centres, from general anaesthesia to deep or conscious sedation. We assessed current sedation practices for AF ablation and its evolution over the last decade with an online survey completed by centres regularly performing AF ablation worldwide.
Among the 297 centres participating, the median number of AF ablation procedures increased from 91 [43; 200] to 200 [74; 350] per year (P<0.001) between 2010 and 2019 with a significant rise in cryoablation. In 2019, the most used sedation technique was general anaesthesia (40.5%), followed by conscious sedation (32.0%) and deep sedation (27.5%). Between 2010 and 2019, the proportion of procedures performed under general anaesthesia (+4,4%) and deep sedation (+4,8%) increased, whereas the use of conscious sedation decreased (-9.2%). The most commonly used hypnotic drugs were propofol and midazolam, whereas the most commonly used opioid drugs were remifentanyl and fentanyl.
In conclusion, this worldwide survey shows that the number of AF ablation procedures has more than doubled over the last decade and general anaesthesia remains most commonly used.
The publication is available as a PDF or as an article in EP Europace.
Antithrombotic treatment management in low stroke risk patients undergoing cardioversion of atrial fibrillation <48 h duration: results of an EHRA survey (May 2021)
Data supporting the safety of cardioversion (CV) of atrial fibrillation (AF) without anticoagulation in patients with AF duration <48 h are scarce. Observational studies suggest that the risk of stroke in these patients is very low when the definite duration of the AF episode is <48 h and the clinical risk profile as estimated through the CHA2DS2VASc score is low (a score of 0 for men and 1 for women). As the recent 2020 European Society of Cardiology (ESC) Clinical Practice Guidelines indication for this clinical scenario is based mainly on consensus, we sent out a survey to assess the current clinical practice on anticoagulation prior to and post-CV in patients with AF <24–48 h duration and low stroke risk across centres in Europe. Of the 136 respondents, half were affiliated with university hospitals (68/136; 50%). Non-university hospitals (50/136; 36%) and private hospitals (2/136; 1.4%) accounted for over a third of respondents.
The main findings of our survey were (i) heterogeneity in the anticoagulation management both before and post-CV in low stroke-risk patients with AF <48 h, (ii) higher utilisation of periprocedural low-molecular-weight heparin than of non-vitamin K antagonist oral anticoagulant, (iii) higher utilisation of pre-CV transoesophageal echocardiography for electrical CV than for pharmacological CV regardless of the duration of AF, (iv) high adherence to a four-week post-CV oral anticoagulant (OAC) therapy, mainly for electrical CV, and finally, (v) perceived higher acceptance of lack of post-CV OAC therapy in patients with <24 h than 24-48 h episode duration. The results obtained in this survey highlight the need for more research providing definitive clarification on the safety of CV without anticoagulation in patients with short duration AF.
The publication is available as a PDF or as an article in EP Europace.
Current perspectives on wearable rhythm recordings for clinical decision making: the wEHRAbles 2 survey (April 2021)
This survey aimed to assess the impact of novel wearable heart rhythm devices on physicians’ clinical decision making and to define, how data from these devices should be presented and integrated into clinical practice. The online survey included 22 questions, focusing on the diagnosis of atrial fibrillation (AF) based on wearable rhythm device recordings, suitable indications for wearable rhythm devices, data presentation and processing, reimbursement, and future perspectives. A total of 539 respondents from 51 countries worldwide completed the survey.
Whilst most respondents would diagnose AF (83%), fewer would initiate oral anticoagulation therapy based on a single-lead ECG tracing. Wearable ECG technology is acceptable for the majority of respondents for screening, diagnostics, monitoring, and follow-up of arrhythmia patients, while respondents were more reluctant to use photoplethysmography (PPG) technology for these indications. Wearable single- or multiple-lead ECG technology is accepted for multiple indications in current clinical practice and triggers AF diagnosis and treatment. The unmet needs that call for action are reimbursement plans and integration of wearable rhythm device data into patient’s files and hospital information systems.
The publication is available as a PDF or as an article in EP Europace.
Use and misuse of instant messaging in clinical data sharing: the EHRA-SMS survey (March 2021)
Instant messaging (IM) enables medical professionals to quickly share clinical data with their peers for counselling. The aim of this survey was to assess the habits related to IM, their application in clinical practice and the perceived pros and cons.
A total of 287 subjects from 33 countries responded to the survey (mean age 43 years, 74.8% male). Of all respondents, 88.3% routinely send and 90.3% receive clinical data through IM which was second only to face-to-face contact as the preferred method for sharing clinical data. Twelve-lead electrocardiograms, medical history and echo loops were the data shared most often. Nearly half of the clinical data that are sent or received are not anonymised.
Instant messaging apps are used by medical professionals worldwide to share and discuss clinical data and are preferred to many other methods of data sharing, being second only to face-to-face contact. IM is often used to share many different types of clinical data, being perceived as a fast and easy way of communication. Medical professionals should be aware of the appropriate use of IM to prevent legal and privacy issues.
The publication is available as a PDF or as an article in EP Europace.
Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey (January 2021)
The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. This survey explored how physicians decide on ATT for this patient population by addressing issues such as timing of restarting or initiating ATT, the first choice of ATT, and clinical factors that influence physicians’ decision making on ATT post-ICH.
The interpretation of CHA2DS2-VASc score components in clinical practice: A joint survey by European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals and the European Society of Cardiology Council on Stroke (December 2020)
This joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the ‘C’ component, as well as the ‘one-off high reading of blood pressure’ to score on the ‘H’ component. Greater confidence was expressed in scoring the ‘H’ component (72.3%) compared with the ‘C’ (46.2%) and ‘V’ (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%).
The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the ‘C’, ‘H’, and ‘V’ elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications.
Utilisation and perception of same-day discharge in electrophysiology procedures and device implantations (November 2020)
The aim of this European Heart Rhythm Association (EHRA) survey was to assess the utilisation of same-day discharge (SDD) in electrophysiology (EP). The concept of SDD was most commonly used following implantations of cardiac event recorders (97%), diagnostic EP procedures (72.2%), and implantations of pacemakers with one or two intracardiac leads (50%), while the lowest SDD utilisation was observed after catheter ablations of left atrial or ventricular arrhythmias. Within SDD-experienced centres, ∼90% respondents stated that this discharge concept is recommendable or highly recommendable and reported that rates of increased rehospitalisation and complication rates were low.
Further research is needed to confirm or disprove existing and expected benefits and obstacles.
Diagnosis, family screening, and treatment of inherited arrhythmogenic diseases in Europe (October 2020)
The spectrum of inherited arrhythmogenic diseases (IADs) includes disorders without overt structural abnormalities (i.e. primary inherited arrhythmia syndromes) and structural heart diseases (i.e. arrhythmogenic ventricular cardiomyopathy, hypertrophic cardiomyopathy). The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate current clinical practice and adherence to 2015 European Society of Cardiology Guidelines regarding the management of patients with IADs.
A 24-item centre-based online questionnaire was presented to the EHRA Research Network Centres and the European Cardiac Arrhythmia Genetics Focus Group members. There were 46 responses from 20 different countries.
Mobile health applications for managing atrial fibrillation for healthcare professionals and patients: an EHRA systematic review (August 2020)
A plethora of mobile health applications (m-health apps) to support healthcare are available for both patients and healthcare professionals (HCPs) but content and quality vary considerably and few have undergone formal assessment. The aim of this paper was to systematically review the literature on m-health apps for managing atrial fibrillation (AF) that examine the impact on knowledge of AF, patient and HCP behaviour, patients’ quality-of-life, and user engagement.
Mobile health apps demonstrate improvements in patient knowledge, behaviour, and quality of life. Studies formally evaluating the impact of m-health on HCP behaviour are scarce and larger-scale studies with representative patient cohorts, appropriate comparators, and longer-term assessment of the impact of m-health apps are warranted.
Knowledge gaps, lack of confidence, and system barriers to guideline implementation among European physicians managing patients with CIED lead or infection complications: an EHRA/ESC educational needs assessment survey (July 2020)
As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians.
Guideline-adherent management is associated with improved prognosis in patients with CIED infection or lead problems, but is insufficiently implemented in practice. The European Heart Rhythm Association (EHRA) with the support of the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery, performed a multinational educational needs assessment study in ESC member countries, directed at physicians who might be confronted with CIED patients with complications.
We identified major gaps in physicians’ knowledge and skills across all stages of CIED care. These gaps should be addressed by targeted educational activities and streamlining referral pathways.
The Read the publication.
Contemporary management of patients with syncope in clinical practice (May 2020)
Syncope is a heterogeneous syndrome encompassing a large spectrum of mechanisms and outcomes. The European Society of Cardiology published an update of the Syncope Guidelines in 2018. The aim of the present physician survey was to capture contemporary management of syncope and guideline implementation among European physicians.
While revealing an increased awareness of syncope and good practice, our study identified important unmet needs regarding the optimal management of syncope and variable syncope guideline implementation.
Management of atrial fibrillation in patients with chronic kidney disease in clinical practice: a joint EHRA and ERA/EDTA physician-based survey (January 2020)
The European Heart Rhythm Association (EHRA) and European Renal Association/European Dialysis and Transplantation Association (ERA/EDTA) jointly conducted a physician-based survey to gain insight into the management of atrial fibrillation (AF) in patients with chronic kidney disease (CKD) and adherence to current European Society of Cardiology AF Guidelines in contemporary clinical practice.
The survey provided important insights into contemporary management of AF patients with CKD in clinical practice, revealing certain differences between nephrologists and cardiologists and highlighting shared and specific knowledge gaps and unmet needs.
These findings emphasize the need for streamlining the care for AF patients across different specialties and may inform development of tailored education interventions.
Diagnosis and management of LAA thrombus in patients with AF undergoing cardioversion or percutaneous left atrium procedures (September 2019)
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown.
The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC.
The study revealed a significant utilisation of TOE before AF CV or ablation regardless of the type or duration of AF, which represented a more conservative strategy than suggested by current AF guidelines.
Antithrombotic treatment in patients with atrial fibrillation and acute coronary syndromes (February 2019)
The management of an acute coronary syndrome (ACS) in a patient with existing atrial fibrillation (AF) often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment to reduce the risk of in-stent thrombosis or recurrent cardiac events.
Current practice recommendations are based largely on consensus option as there is limited evidence from randomised controlled trials. Prior to the launch of the new European Heart Rhythm Association (EHRA) consensus document, a survey was undertaken to examine current clinical management of these patients across centres in Europe.
Forty-seven centres submitted valid responses, with the majority (70.2%) being university hospitals. This EHRA survey demonstrated overall the management of ACS in AF patients is consistent with the available guidance. Read the publication.
Translating guidelines into practice for the management of atrial fibrillation (June 2018)
Despite the huge progress made in the both understanding the mechanisms and the management of atrial fibrillation (AF) this arrhythmia still represents an important health and social burden. Atrial fibrillation is increasing in frequency and is a major cause of death, stroke, heart failure, cognitive decline, and hospitalisations.
New data have emerged emphasizing the multidisciplinary approach to better management of this common arrhythmia. The scope of the current survey is to evaluate the extent of the disparities between clinical practice and the 2016 AF European Society of Cardiology (ESC) guidelines. Read the publication.
Translating guidelines into practice : Management of patients with ventricular arrhythmias and prevention of sudden cardiac death (June 2018)
Prevention of sudden cardiac death (SCD) remains a partly unsolved task in cardiology. The European Society of Cardiology (ESC) Guidelines on management of patients with ventricular arrhythmias and prevention of SCD published in 2015 considered the new insights of the natural history of diseases predisposing to SCD.
The guidelines improved strategies for management of patients at risk of SCD and included both drug and device therapies. The intention of this survey was to evaluate the extent of the disparities between daily clinical practice and the 2015 SCD ESC guidelines among electrophysiology centres in Europe. The Read the publication.
Use of leadless pacemakers in Europe: results of the European Heart RhythmAssociation survey (March 2018)
The purpose of this European Heart Rhythm Association (EHRA) survey is to provide an overview of the current use of leadless pacemakers (LLPM) across a broad range of European centres. An online questionnaire was sent to centres participating in the EHRA Electrophysiology Research Network.
Questions dealt with standards of care and policies used for patient management, indications, and techniques of implantation of LLPM. In total, 52 centres participated in the survey. Read the publication.
This document is supported by Medtronic in the form of an educational grant. Its content has not been influenced in any way by its sponsor.
Management of ventricular tachycardia in the ablation era: results of the European Heart RhythmAssociation survey (December 2017)
Patients with sustained ventricular tachycardia (VT) are at risk of sudden death. Treatment options for VT include antiarrhythmic drug therapy, insertion of an implantable cardioverter-defibrillator, and catheter ablation. Evidence on indications for VT ablation, timing, ablation strategies, and periprocedural management is sparse.
The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding management of VT among the European countries. An electronic questionnaire was sent to members of the EHRA Electrophysiology Research Network. Responses were received from 88 centres in 12 countries. The results have shown that management of VTs is very heterogeneous across the participating centres. Read the publication.
Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias (October 2017)
The age of patients presenting with complex arrhythmias is increasing. Frailty is a multifaceted syndrome characterised by an increased vulnerability to stressors and a decreased ability to maintain homeostasis. The prevalence of frailty is associated with age.
The aims of this European Heart Rhythm Association (EHRA) EP Wire survey were to evaluate the proportion of patients with frailty and its influence on the clinical management of arrhythmias. A total of 41 centres—members of the EHRA Electrophysiology Research Network—in 14 European countries completed the web-based questionnaire in June 2017. Access the results and the publication.
Left atrial appendage occluder implantation in Europe: indications and anticoagulation post-implantation (August 2017)
In patients with atrial fibrillation (AF), the left atrium is a common source for thrombo-embolic events. Approximately 90% of all thrombi identified in the left atrium can be localized in the left atrial appendage (LAA). The gold standard for stroke prevention in patients with non-valvular AF and high stroke risk is oral anticoagulation (OAC) therapy with a vitamin K antagonist (VKA) or a non-VKA oral anticoagulant (NOAC). However, OAC therapy is associated with a significant bleeding risk. Percutaneous LAA occluder (LAAO) have been developed aiming at stroke prevention without the need for
OAC therapy, particularly in patients with a history of bleeding on OAC therapy, high bleeding risk or contraindications to OAC therapy.
The purpose of this European Heart Rhythm Association (EHRA) EP Wire survey was to assess the indications used in the different centres, as well as the anticoagulation protocols post-LAAO implantation.
Access the results and the publication.
Approach to cardio-oncologic patients with special focus on patients with cardiac implantable electronic devices planned for radiotherapy (July 2017)
The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding cardio-oncologic patients, with special focus on patients with cardiac implantable electronic devices (CIEDs) planned for anticancer radiotherapy (RT), among members of the EHRA electrophysiology research network. Of the 36 responding centres, 89% managed patients who were diagnosed or treated oncologically, and this diagnosis affected 1–5% of cardiovascular patients in majority of centres (57%).
The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding the management of cardio-oncologic patients, with special focus on patients with CIED planned for anticancer RT. Access the results and the publication.
Implantable cardioverter defibrillator use for primary prevention in ischaemic and non-ischaemic heart disease —indications in the post-DANISH trial era (April 2017)
Implantable cardioverter-defibrillator (ICD) is the standard of care for prevention of sudden cardiac death (SCD) in high-risk patients. For primary prevention of SCD, in patients with ischaemic heart disease, there is more robust data on the effect of ICD therapy compared with patients with non-ischaemic heart disease, but current real-life practice may differ substantially. The aim of this European Heart Rhythm Association survey was to evaluate the clinical practice regarding implantation of ICD for primary prevention among European countries in patients with non-ischaemic and ischaemic heart disease. Furthermore, we wanted to investigate the impact of the results of the recently published DANISH trial on clinical practice among European countries. In total, 48 centres from 17 different countries responded to the questionnaire. Access the results and the publication.
Cryoablation for treatment of cardiac arrhythmias (January 2017)
Cryoablation is a relatively new technique for catheter ablation. It has been widely employed to treat various cardiac arrhythmias.
Since the development of cryo-balloon technique, cryoablation has attracted increasing attention as a treatment method for atrial fibrillation (AF). Both cryo-energy and radio-frequency energy are recommended for pulmonary vein isolation in AF patients. Although the number of cryoablation procedures is constantly growing, many clinical issues are still unclear. Randomised controlled data regarding the procedural details are limited and there may be considerable variability between operators and centres.
The aim of this survey was to provide an insight into the current practice in Europe regarding the cryoablation therapy for different cardiac arrhythmias and to identify the issues which may need further investigations. Access the results and the publication.
Catheter ablation for atrial flutter: a survey by the European Heart Rhythm Association and Canadian Heart Rhythm Society (December 2016)
The purpose of this EP wire survey was to examine current practice in the management of both cavotricuspid isthmus (CTI)-dependent and non-CTI-dependent atrial flutter (AFL) ablation amongst electrophysiologists in European and Canadian centres and to understand how current opinions vary from guidelines. The results of the survey have been collected from a detailed questionnaire that was created by the European Heart Rhythm Association Research Network and the Canadian Heart Rhythm Society. Responses were received from 89 centres in 12 countries.
This questionnaire highlights variability within certain aspects of the management of AFL ablation. The variability in opinion regarding other procedural details suggests a need for further research in this area and consideration of the development of guidelines specific to AFL. Overall, there is a reasonable consensus regarding oral anticoagulation and the desired endpoints of ablation for patients with CTI-dependent AFL and for non-CTI-AFL. Access the results and the publication.
Stroke prevention strategies in patients with atrial fibrillation and heart valve abnormalities: perceptions of ‘valvular’ atrial fibrillation: results of the European Heart Rhythm Association survey (October 2016)
High risk of stroke without oral anticoagulant (OAC) therapy, in patients with atrial fibrillation (AF) and mechanical prosthetic heart valves or significant (rheumatic) mitral stenosis, has been well known, but these patients were not included in the historical trials, comparing vitamin K antagonists (VKAs) vs. placebo for stroke prevention in AF. Thromboembolic risk (as well as the risk of OAC-associated bleeding) in AF patients with heart valve abnormalities other than prosthetic mechanical heart valves or significant mitral stenosis is less well known, but recent work suggests that the CHA2DS2-VASc score can assist risk stratification. Along with variable definitions of ‘valvular’ AF used in the literature and contemporary clinical practice, this may create uncertainty among physicians regarding the use of OAC in many AF patients.
The purpose of this European Heart Rhythm Association (EHRA) Scientific Initiatives Committee EP Wire Survey was to assess the perception of ‘valvular’ AF and management of AF patients with various heart valve abnormalities in daily clinical practice in European electrophysiology (EP) centres.
Access the results and the publication.
Implantation of subcutaneous implantable cardioverter defibrillators in Europe: results of the European Heart Rhythm Association survey (August 2016)
The efficacy of implantable cardiac defibrillators (ICDs) for primary or secondary prevention of sudden cardiac death (SCD) has been well documented. Nevertheless, morbidity and complications of these devices have been of major concern. In particular, the presence of a transvenous lead has been perceived as the Achilles' heel of these systems. The recent release of an entirely subcutaneous implantable cardiac defibrillator (S-ICD) possibly represents a further step in the evolution of defibrillator technology. The S-ICD may indeed offer a viable therapeutic option in selected patients at high risk of SCD and in whom pacing is not required and there is growing clinical evidence regarding its safety and efficacy. However, the current clinical practice of S-ICD use among European countries remains largely unknown. The aim of this European Heart Rhythm Association (EHRA) survey was to provide better insight into S-ICD utilisation across a broad range of European centres.
Access the results and the publication.
Non-vitamin K oral anticoagulants in patients with atrial fibrillation after cardiac surgery: the results of the European Heart Rhythm Association survey (June 2016)
Atrial fibrillation (AF) and atrial flutter occur in one-third of the patients after cardiac surgery, most often within the first few days postoperatively. This is associated with longer hospital stay and worse long-term prognosis.There is an increased risk of perioperative stroke, which can be potentially reduced by appropriate anticoagulation. However, anticoagulation in the postoperative period may also increase the risk of bleeding, particularly pericardial bleeding and cardiac tamponade.
The purpose of this European Heart Rhythm Association survey was to assess the current practice concerning the use of oral anticoagulation in patients with postoperative atrial fibrillation (pre-existing or new-onset).
Access the results and the publication.
Replacement of implantable cardioverter defibrillators and cardiac resynchronization therapy devices: results of the European Heart Rhythm Association survey (June 2016)
Implantation of cardiac devices is the most common interventional procedure performed by cardiac electrophysiologists in Europe and worldwide. There is the sufficient knowledge on the clinical benefit of de novo implanted cardiac devices and international guidelines that deal with the indications for sudden cardiac death prevention, cardiac pacing, and cardiac resynchronization therapy (CRT). However, scientific and real-world data, as well as practice guidelines on device replacement, are sparse.
The purpose of this European Heart Rhythm Association (EHRA) EP Wire survey was to assess the management, indications, and techniques for implantable cardioverter defibrillator (ICD) and CRT device replacement in Europe. Access the results and the publication.
The role of the arrhythmia team, an integrated multidisciplinary approach to treatment of patients with cardiac arrhythmias (May 2016)
Management of patients with cardiac arrhythmias is increasingly complex because of continuous technological advance and multifaceted clinical conditions associated with ageing of the population, the presence of co-morbidities and the need for polypharmacy. The aim of this European Heart Rhythm Association Scientific Initiatives Committee survey was to provide an insight into the role of the Arrhythmia Team, an integrated, multidisciplinary approach to management of patients with cardiac arrhythmias. Forty-eight centres from 18 European countries replied to the Web-based questionnaire. Access the results and the publication.
The use of wearable cardioverter-defibrillators in Europe (February 2016)
Implantable cardioverter-defibrillators (ICDs) have proved effective in the primary and secondary prevention of sudden cardiac death (SCD). However, a significant proportion of patients presents with contraindications to ICD or does not meet the criteria for ICD implantation, as defined by current guidelines. The wearable cardioverter-defibrillator (WCD) may be considered an attractive temporary alternative to ICD.
The aim of this European Heart Rhythm Association (EHRA) survey was to collect data on the use of wearable cardioverter-defibrillators (WCDs) among members of the EHRA electrophysiology research network. Access the results and the publication.
Management of atrial fibrillation in patients with chronic kidney disease in Europe (December 2015)
Chronic Kidney Disease (CKD), defined as a glomerular filtration rate (GFR) of <60 mL/min per 1.73 m2 for >3 months, is present in >10% of adults. There is a complex interplay between the kidney and cardiovascular function, and even mild CKD is associated with increased cardiovascular morbidity and all-cause mortality.
The purpose of this European Heart Rhythm (EHRA) Scientific Initiatives Committee EP Wire Survey was to assess ‘real-world’ practice in the management of AF patients with CKD in the European electrophysiology (EP) centres. Access the results and the publication.
Review of 6 years of EP Wire activity (November 2015)
The purpose of this review was to summarize the results of past EP wires in terms of coverage of the main topics in EP and to evaluate the acceptance and the feedback from the responding physicians, in order to increase the participation in the surveys and to better address the research needs and aspirations of the European EP community. Access the results and the publication.
Current ablation techniques for persistent atrial fibrillation in Europe (October 2015)
Catheter ablation is now a well-established treatment option for atrial fibrillation (AF), with rising numbers of procedures conducted worldwide.Patients with persistent AF represent a significant proportion of ablation candidates.
The aim of this survey was to provide insight into current practice regarding ablation of persistent atrial fibrillation (AF) among members of the European Heart Rhythm Association electrophysiology research network. Access the results and the publication.
This is EP Wire has been conducted thanks to an unrestricted educational grant from Medtronic.
Management of arrhythmias detected by implanted cardiac devices (September 2015)
The management of arrhythmias detected by devices is challenging, especially when they are asymptomatic. We are seeking to assess how Cardiologists manage symptomatic and asymptomatic arrhythmias detected by implanted cardiac devices. Access the results and the publication.
Management of ventricular tachycardia – antiarrhythmic drugs, catheter ablation and implantable cardioverter defibrillator therapies (August 2015)
This questionnaire aims at obtaining information on European-wide clinical practice in the management of ventricular tachycardia with emphasis on treatments use of antiarrhythmic drugs, implantable defibrillator and catheter ablation therapies.
Results | Full article
Routines for fluoroscopy use in ep-clinical practice in Europe (July 2015)
This survey evaluates and compares current and former routines for fluoroscopy use in EP and if there is any difference for physicians and patients.
Results | Full article
How are European patients at risk of malignant arrhythmias or sudden cardiac death identified and informed about their risk profile (June 2015)
The survey will include several questions about the strategy and the clinical tools for identification of best candidates to life-threatening therapy such as implantable cardioverter defibrillator (ICD).
Preference for oral anticoagulation therapy for patients with atrial fibrillation in Europe in different clinical situations (May 2015)
The purpose of this European Heart Rhythm Association (EHRA) survey is to assess the clinical practice in relation to the use of oral anticoagulation therapy for patients with atrial fibrillation (AF) in Europe, in different clinical situations.
Left atrial appendage closure–indications techniques and outcomes (April 2015)
The purpose of this EP Wire is to investigate how these catheter-based methods for LAAO are being used in Europe regarding indications, techniques and outcomes.
How are patients with atrial fibrillation approached and informed about their risk profile and available therapies in Europe? (March 2015)
With this EP Wire Survey, we aim to elicit common practices in approaching AF patients and informing them about their risk profiles and available therapies in the EP Network centres in Europe.
Clinical management of arrhythmias in elderly patients (February 2015)
The purpose of this survey was to assess clinical practice in the management of cardiac arrhythmias in elderly patients (age ≥75 years) in the European countries. The data are based on an electronic questionnaire sent to the European Heart Rhythm Association Research Network members. Responses were received from 50 centres in 20 countries. The results of the survey have shown that management of cardiac arrhythmias is generally in accordance with the guidelines and consensus recommendations on the management of cardiac arrhythmias, although there are some areas of variation, especially on age limit and exclusion of elderly patients for anticoagulation, ablation, and device therapy.
Do cardiologists follow the European guidelines for cardiac pacing and resynchronisation therapy? (January 2015)
The purpose of this European Heart Rhythm Association (EHRA) EP wire survey was to evaluate the implementation of the current guidelines for cardiac pacing and cardiac resynchronization therapy (CRT) in Europe. A total of 48 centres replied to the survey, 34 of them (71%) were university hospitals. All responding centres implement CRT in patients with classical indications. The results of this survey showed a good adherence to some of the current recommendations. Still, some reluctance exists when offering the device therapy to patients with QRS duration in the lower range.
Management of malfunctioning and recalled pacemaker and defibrillator leads
The aim of this survey was to describe the different strategies regarding the management of malfunctioning and recalled pacemaker and defibrillator leads across Europe. A questionnaire has been designed to assess the current practice and physician’s approach to the management of leads which are faulty, unnecessary, and/or recalled. Responses to the questionnaire were received from 34 hospitals—members of the European Heart Rhythm Association (EHRA) electrophysiology (EP) research network. The survey involved both very high and low volume implanting centres, with 85% of the responding centres performing lead extraction.
The survey provides a panoramic view of operator’s decision making in the field of malfunctioning, recalled, and redundant leads and outlines a common point of view on lead abandonment and factors influencing the decision about lead extraction. The main factors strongly influencing the decision making were patient’s age (59%), the presence of the damaged leads (44%), and the lead dwelling time (44%). Regarding the lead abandonment, the main concern (61%) was the potential greater difficulty associated with lead extraction in the future. High volume extracting centres showed a greater propensity to removing the malfunctioning or recalled leads compared with low volume or non-extracting centres. This EP Wire survey gives a snapshot of the operators’ approaches and options regarding redundant, malfunctioning, and recalled lead management and may form the basis for future prospective research on this topic.
Management of paediatric arrhythmias
The vast majority of paediatric arrhythmias concerns childer older than 1 year and patients with grown-up with grown-up congenital heart disease. In 65% of the hospitals, there is a specialised paediatric centre, and the most commonly observed arrhythmias include Wolff-Parkinson-White syndrome and atrioventricular nodal re-entry tachycardias (90.24%).
Lone AF, workup and management
Thirty-two European centres, all members of the EHRA EP research network, responded to this survey and completed the list of questions. The prevalence of lone atrial fibrillation (AF) is ≤ 10% in 19 centres (60%). Isolated left atrial enlargement and left ventricular dysfunction represents heart disease according to 50% and 84% of participating centres, respectively, and excludes the diagnosis of lone AF.
Arrhythmia detection. Common practice - use of ECG monitoring systems (24-72 hrs, ELR, ILR) for arrhythmias detection
The aim of this European Heart Rhythm Association (EHRA) survey was to assess the use of different monitoring techniques in the evaluation of patients with unexplained syncope, palpitations and in those with established diagnosis of atrial fibrillation. Forty-five centres in Europe answered the questionnaire and the majority (78%) were university hospitals.
Standards for device implantation and follow-up: personnel, equipment and facilities
Cardiac device implantation is the most common of all invasive cardiac electrophysiological procedures. Over 250,000 devices are implanted each year in Europe.
The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the facilities, personnel, and protocols of members of the EHRA electrophysiology (EP) research network involved in device implantation. Cardiac device implantation as a day case is the planned admission for routine elective device implantation in 30% of hospitals, 47% of hospitals have a single night stay, and 23% of hospitals have admission durations of two or more nights. Device implantation is available as a 24 h service, 365 days a year in 38% of hospitals. The commonest other model was a daytime service on weekdays in 45% of hospitals.
Personnel, equipment, and facilities for electrophysiological and catheter ablation procedures in Europe
Clinical electrophysiology (EP) and catheter ablation of arrhythmias are rapidly evolving in recent years. More than 50 000 catheter ablations are performed every year in Europe. Emerging indications, an increasing number of procedures and an expected high quality require national and international standards as well as trained specialists. The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the practice of requirements for EP personnel, equipment, and facilities in Europe.
The survey reflects the current EP personnel situation characterised by a high training requirement and specialisation. Arrhythmia sections are still most often part of cardiology departments and the head of cardiology is seldom a heart rhythm specialist. Currently, the vast majority of EP physicians are men, although, in the subgroup of physicians younger than 40 years, the proportion of women is increasing.
Current implantable cardioverter-defibrillator programming in Europe
The purpose of this European Heart Rhythm Association (EHRA) survey was to examine the current practice of the choice of implantable cardioverter-defibrillator (ICD) type, use of defibrillation testing, and ICD programming for detection and therapy of ventricular arrhythmias. In accordance with recent guidelines and the results of observational studies, the majority of EHRA research network centres reported a high utilization rate of dual-chamber ICDs in the presence of symptomatic and asymptomatic sinus node dysfunction, bi-ventricular ICD in high degree atrioventricular block and QRS duration ,120 ms, and a limited use of defibrillation testing either in primary and secondary prevention settings. Activation of the long ventricular tachycardia (VT) detection window, slow VT zone, anti-tachycardia pacing before shock for slow and fast VT, and atrial tachyarrhythmia discrimination were considered useful in ICD programming for the majority of patients.
Stroke and bleeding risk evaluation in Atrial Fibrillation: Results of the European Heart Rhythm Association survey
The aim of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in relation to stroke and bleeding risk evaluation in atrial fibrillation, particularly regarding the use of risk evaluation schemes, among members of the EHRA electrophysiology (EP) research network. In this EP Wire survey, we have provided some insights into current practice in Europe for the use of these risk assessment schemes. There were some obvious practice differences. However, reassuring information on current practice in Europe was evident, but more focus on renal function is warranted, especially facing the fact that novel oral anticoagulants are used for antithrombotic therapy.
Diagnosis and management of patients with inherited primary arrhythmia syndromes- European Clinical Practice
Inherited arrhythmia disorders associated with structurally normal heart (i.e. long and short qt syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, early repolarization syndrome, idiopathic ventricular fibrillation) caused 10% of 1.1 million sudden deaths in Europe and the USA. The purpose of this European Heart Rhythm Association (EHRA) electrophysiology wire survey was to assess the European clinical practice adopted for the diagnosis and management of these disorders. The survey was based on an electronic questionnaire sent out to the EHRA Research Network centres. Responses were received from 50 centres in 23 countries. The results of the survey show that inherited arrhythmia syndromes have a relatively low burden and are diagnosed and managed in accordance with the current guidelines. However, more than 50% of centres do not participate in any existing registry underlining the need for establishing a pan-European registry of these disorders.
Periprocedural management of Atrial Fibrillation Ablation
The purpose of this EP Wire survey was to assess clinical practice in the periprocedural management of atrial fibrillation ablation. This survey is based on an electronic questionnaire sent to the European Heart Rhythm Association Research Network members. Responses were received from 78 centres in 20 countries. The results of the survey have shown that periprocedural management is generally in accordance with guidelines and consensus recommendations on ablation for atrial fibrillation ablation, although there are some areas of variation. Differences between high and low-volume centres are observed with respect to patient selection, antiarrhythmic drug management, and heparin bridging.
European management strategy for AF patients presenting with acute coronary syndrome.
Given a lack of the precise guidelines for treatment of patients with AF and ACS, the aim of this survey is to provide an insight into current practice in Europe regarding treatment of patients with nonvalvular AF presenting with an ACS.
Remote Monitoring on Cardiac Implantable Electronic Devices in Europe
The aim of this survey was to provide insight into current practice regarding the use of remote monitoring for cardiac devices in Europe.
Current investigation and management of patients with syncope
The aim of this European Heart Rhythm Association (EHRA) survey was to provide an insight into the current practice of work-up and management of patients with syncope among members of the EHRA electrophysiology research network.
Preference of various techniques-tools for device implantation
The aim of this survey is to explore procedural practice in terms of tools and techniques used for CIED ( Cardiac Implantable Electronic Devices) implantation in European countries.
The practice of use of NOAC therapies in Europe
The purpose of this EP Wire survey is to have a picture of daily practice regarding the everyday use of NOACs in Europe
Imaging techniques in electrophysiology and implantable device procedures
The purpose of this European Heart Rhythm Association (EHRA) survey is to assess the implementation and use of imaging techniques in cardiac electrophysiology (EP) and device procedures across European cardiovascular centres.
X-ray exposure for implanting and ablating physicians
The aim of this survey is to evaluate physician’s and authorities policies and clinical practices when using occupational X-ray during ablation procedures and device implantation.
Prophylactic antiarrhythmic drugs for atrial fibrillation (AF)
The aim of this survey was to provide insight into the current use of prophylactic antiarrhythmic drugs for atrial fibrillation (AF) in European countries.
Management pre-excitation syndromes
The aims of this survey were to provide insight into treatment activity, the strategy of treatment and risk stratification of patients with asymptomatic and symptomatic ventricular preexcitation across Europe.
Use of atrial appendage occluder for stroke prevention
The use of left atrial appendage occlusion to reduce the risk of stroke in atrial fibrillation has recently gained much attention. The aim of this EP wire survey is to know the practice of European centres regarding use, peri-procedural management and outcomes of left atrial appendage occlusion devices.
Management of patients with sustained ventricular tachycardia
Ventricular tachycardia (VT) is a complex arrhythmia syndrome including different etiologies. This EP WIRE provided us with a picture about diagnostic and therapeutic management of patients with sustained VT of the different experience in several European countries.
Current practice on transvenous lead extractions
Lead extraction is a rapidly expanding field that is increasing along with the number of devices and leads implanted and which is also partially unexplored across European countries concerning appropriate indications, techniques, success rates, safety and follow-up. A Lead Extraction Registry is about to be launched and should start by the autumn. The aim of this registry is to improve healthcare standards and education by generating data from a high number of representative centres across Europe.
Periprocedural anticoagulation therapy
This EP Wire surveyed clinical practice with regard to the use of antithrombotic therapy in relation to device implantation (pacemakers, ICT, resynchronisation therapy) and atrial fibrillation ablation in 71 centres —members of the European Heart Rhythm Association research network. The results of this survey show variation in clinical practice, but reassuringly some consistency with guidelines and consensus recommendations on the management of periprocedural (devices, ablation) antithrombotic therapy.
Surgical and hybrid AF ablation procedures
Surgical techniques for curative ablation of atrial fibrillation, have evolved from the original Cox Maze-III procedure to minimally invasive stand alone procedures with new energy sources and electrophysiological validation of the lesion set which requires close collaboration between cardiologists and cardiac surgeons.
Management of survival of out of hospital cardiac arrest
Out of hospital cardiac arrest (OHCA) is a leading cause of death among adults in the European countries. Survival rates vary widely across the European countries. The results of this EP Wire survey enabled EHRA to compare interventions modalities, local organisations, outcomes and identifies opportunities to improve the quality of care and ascertain whether resuscitation and following cure are provided according to evidence-based guidelines.
Definitions: An OHCA is defined as cessation of cardiac mechanical activity that is confirmed by the absence of signs of circulation and that occurs outside of a hospital setting. The majority of such events have a cardiac aetiology.
Cardiac resynchronisation therapy
(AF, RBBB, Guidelines, Nonrespond)
Atrial fibrillation ablation techniques and strategies
This survey, designed for persons who perform AF ablation in their cath labs, collected 50 answers.
Device Infections
Infections related to Cardiac Implantable Electronic Devices have grown in the last decade. The aim of this EP wire survey is to know the practice of European Centres regarding diagnosis, treatment and prophylactic treatment of CIED infections.
MRI in device patients
A significant part of patients with cardiac implantable electronic devices (CIEDs) may develop a need to perform magnetic resonance imaging (MRI) study. The number of MRI-compliant devices is still low, and the data on performing MRI in older (non-MRI-compliant) devices is scarce. The purpose of this survey is to get information about practices of dealing with the patients with implanted CIEDs and MRI procedures in European centres.
Validation of success following atrial fibrillation (AF) ablation
Catheter ablation of AF has become an important treatment modality in recurrent symptomatic AF when antiarrhythmic drug therapy has been ineffective or associated with unacceptable side effects. However, catheter ablation of atrial fibrillation is not a standardised procedure and indication and treatment strategies differ greatly between hospitals. Furthermore, there is neither a clear definition of what constitutes a successful ablation procedure nor agreement on validation approaches to the various currently used definitions of success. Thus the clinical practice of AF ablation varies greatly as does follow-up (FU) strategy.
Attitude towards redundant leads and the practice of lead extractions
This survey has compared attitudes towards (endocardial) lead extraction, among European electrophysiology centres, with special attention paid to ‘redundant leads’. The main findings of this survey are:
- Most of the centres performing lead extractions do so in low volume even though the number of implants may be high.
- Approaches to the practice of lead extraction are based largely on clinical experience and individual sentiment but not on a rigorous evidence based.
- Traction alone or in combination with extraction tools (but not laser) are commonly used for extraction.
- The perception of the need for involvement of cardio-thoracic surgeon varies.
Screening for, and management of, possible arrhythmogenic syndromes (channelopathies/ion channel diseases)
This survey assesses the current management strategies for individuals with electrocardiographic features, suggesting an arrhythmogenic syndrome [including long QT syndrome (LQTS), Brugada syndrome (BS), catecholaminergic polymorphic ventricular tachycardia (CPVT) or short QT syndrome] or family members of patients with a known arrhythmogenic syndrome, in 44 large European centres.
The principal findings of this survey were:
- the number of new patients with arrhythmogenic syndromes (symptomatic and asymptomatic) is relatively small;
- the clinical work-up of these patients consists mainly of non-invasive tests;
- a relatively high use of genetic testing is noted, especially in LQTS and CPVT;
- EP testing is commonly performed in asymptomatic BS patients and in family members of symptomatic BS patients; and
- the majority of European electrophysiologists focus on first-degree relatives when dealing with family members of an index patient.
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