Comprehensive Arrhythmia Care: Optimizing DOACs, PFA Protocols, and 3D Mapping

Lunch Symposium 2, entitled “Optimizing Stroke Prevention in NVAF: From Anticoagulant Choice to Real-World Outcomes”, was moderated by Budi Baktijasa Dharmajati, MD, PhD, and Hauda El Rasyid, MD. Opening the session, Simon Salim, MD, advocated for proactive anticoagulation, reminding clinicians that risk stratification scores like CHA₂DS₂-VASc and HAS-BLED are meant to indicate therapy rather than justify withholding protection. Presenting trial evidence, he highlighted the superior efficacy and safety of Direct Oral Anticoagulants (DOACs), especially apixaban, over traditional antithrombotics across diverse demographics. Then, Ragil Nur Rosyadi, MD focused on complex cohorts, including patients with renal impairment, extreme body weights, advanced age, and frailty, strongly cautioning against routine underdosing and unjustified treatment omission. Concluding the panel, Muhammad Muqsith, MD, detailed the shift toward targeted anticoagulation following AF ablation and left atrial appendage closure. He stressed that interventions do not entirely eliminate thromboembolic hazards, as regular risk reassessment and shared decision-making before stopping oral anticoagulation are required. An engaging interactive discussion ended the session.

Next, moderated by Sunu Budhi Raharjo, MD, PhD, and Aruman Yudanto, MD, Symposium 14, entitled “PFA for Managing Challenging Case in AF — Heart Failure, Redo, Non PVI”, explored Pulsed Field Ablation (PFA) systems and substrate-based strategies in complex atrial fibrillation cases. The session opened from a technological standpoint as Prof. Datuk Azlan Hussin, MD dissected innovations in platforms like Affera. He demonstrated how specialized balloon catheters can stabilize electrode spacing, prevent backward shunting, and secure uniform voltage delivery. Addressing complex redo cases with left ventricular dysfunction, Muhammad Yamin, MD, PhD noted that AF recurrence, despite durable pulmonary vein isolation points to extra-PV substrates, most commonly managed with posterior wall modification. He also highlighted the need for large randomized trials to standardize redo protocols. To wrap up, Prof. Yoga Yuniadi, MD, PhD examined the occult substrate in structural heart disease, where heavy remodeling, fibrosis, autonomic imbalance, and mechanical strain may heighten AF recurrence. He urged electrophysiologists to reconsider traditional procedural endpoints, highlighting that success in advanced disease should be measured by substantial reductions in AF burden and symptom relief rather than sinus rhythm alone.

Lastly, Symposium 17, entitled “Supraventricular Arrhythmia Ablation Revisited: Insights from High-Density Mapping Technologies”, moderated by Prof. Yoga Yuniadi, MD, PhD, and Giky Karwiky, MD, showcased how high-density mapping is transforming the precision of SVT interventions. Prof. Datuk Azlan Hussin, MD commenced the talks by demonstrating how high-density electroanatomical mapping accurately identifies critical conduction channels and reentrant isthmuses within complex anatomies. Beny Hartono, MD, followed with an in-depth look at open-window mapping for symptomatic accessory pathways. He explained how this visualization technique rapidly isolates vital electrograms and pathway insertion points, thereby reducing radiofrequency delivery, procedure duration, and radiation exposure. Finally, in regards to zero-fluoroscopy environments, Alexander Edo Tondas, MD, PhD, introduced the concept of the “apron-less” catheter laboratory utilizing Slow Pathway Late Activation Mapping (SLAM). He noted that while contact-independent, AI-integrated virtual histology holds strong promise for AVNRT and atypical substrates, dedicated multicenter prospective trials remain essential to validate long-term clinical outcomes against standard electroanatomical mapping workflows.