EP Edge Journal Watch Issue 17 April 2026: CLOSURE-AF, Left Atrial Appendage Closure vs Medical Therapy, CRT Pacing Trials, PFA Cerebral Emboli, and ViV-TAVR Pacemaker Risk

In this episode of EP Edge Journal Watch, Dr. Niraj Sharma reviews five clinically important studies spanning atrial fibrillation, structural heart intervention, heart failure pacing, and contemporary ablation safety. The episode opens with CLOSURE-AF, the randomized trial comparing left atrial appendage closure (LAAC) with physician-directed best medical therapy in older, high-risk patients with atrial fibrillation. The discussion examines whether LAAC can truly match or surpass modern anticoagulation-based care for stroke prevention, why the anticipated bleeding advantage did not clearly materialize, and how these findings should recalibrate clinical thinking around left atrial appendage closure and Watchman-era device strategies in 2026.The episode then turns to cardiac resynchronization therapy and the ongoing debate over conduction system pacing versus conventional biventricular pacing. Dr. Sharma contrasts the HeartSync-LBBP randomized trial with PhysioSync-HF, two studies that move in opposite directions and together provide a practical reality check for electrophysiologists. Key themes include left bundle branch pacing, conduction system pacing, operator experience, reverse remodeling, heart-failure hospitalization, and whether left bundle branch area pacing is ready to replace biventricular pacing as the default CRT strategy.The final segments focus on procedural safety and conduction risk. A mechanistic study comparing pulsed field ablation with high-power short-duration radiofrequency ablation evaluates cerebral micro-embolization detected by transcranial Doppler, emphasizing that embolic burden may be platform-specific rather than a generic property of PFA. The episode also reviews predictors of permanent pacemaker implantation after valve-in-valve TAVR, including bifascicular block, deeper septal implantation, and new bundle-branch block after the procedure. This episode is especially relevant for clinicians interested in atrial fibrillation, LAAC, CRT, conduction system pacing, pulsed field ablation, cerebral embolic risk, and TAVR-related conduction disease.