Doctors & patients are saying about 'A-Fib.com'...


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Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


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Roy Salmon, Patient, A-Fib Free,
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"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

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Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

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Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


AF Symposium & other medical conferences articles

2018 AF Symposium Live Procedures: Four New Reports

The live cases are what I like best about attending the AF Symposiums. From world-wide locations via streaming video, we join doctors in their various EP labs while a procedure is underway. The EPs address the symposium audience directly, often fielding questions.

AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

AF Symposium 5-floor-to-ceiling video monitors

We watch these live procedures on floor-to-ceiling high monitor screens. You feel like you are actually in the EP lab with these doctors.

My Favorite and My Most Difficult

While I like live cases the best, they are also my biggest challenge when it comes to writing quality reports.

My difficulty is they are often dealing with devices or treatments I have never heard of before. I take notes as best I can while trying to understand and follow the new concepts and treatments. Happily, I can often send my reports to the doctors involved so they can correct any mistakes and misconceptions.

Four New Live Case Reports

EP and attendee during live case

I’ve posted my first four reports on the live cases (2 more to come). From Belgium to Boston and Texas to Prague, all relate to performing catheter ablations: a device to protect the esophagus, two related to the Left Atrial Appendage (LAA), and a clinical trial of mapping software to better identifying rotors and drivers.

The DV8 Retractor: an Esophageal Deviation Tool from Manual Surgical Sciences with Drs. Kevin Heist, Conor Barrett and Moussa Mansour, all from Massachusetts General in Boston, MA

LAA ClosureInstalling a Coherex WaveCrest LAA Occlusion Device with Dr. Tom De Potter from Aalst, Belgium

RADAR―A Software Breakthrough in Mapping and Identifying A-Fib Rotors and Drivers? with Dr. Petr Neuzil from Prague, Czech Republic

Isolating the Left Atrial Appendage using RF Energy with Dr. Rodney Horton, Texas Cardiac Arrhythmia Institute, Austin, TX

Just Like Being There

These live cases are probably the closest symposium attendees can come to visiting all of these various global locations and observing these world-class master electrophysiologists and their teams.

For many attendees the live cases are often the most innovative and rewarding of the AF Symposium presentations.

Looking for all my 2018 reports?
Go to my 2018 AF Symposium page (link in the left menu column).

My 2018 reports: more to come

2018 AF Symposium Live Case: Isolating the Left Atrial Appendage using RF Energy

by Steve S. Ryan, PhD.

Rodney Horton MD

Dr. Rodney Horton from the Texas Cardiac Arrhythmia Institute in Austin, TX, demonstrated in a live case how to isolate the Left Atrial Appendage (LAA) using Radio Frequency (RF) energy.

Side note: If you been in the EP lab before, the first thing you notice when viewing Dr. Horton at work is no one is wearing the lead aprons and protectors required when using fluoroscopy (x-ray). That’s because he uses 3D non-fluoroscopy (no radiation) imaging techniques.

Patient background: An 82-year old male with persistent A-Fib had a previous PVI but still had Flutter. He was also hypertensive. He also had a dual chamber pacemaker. Previously Dr. Horton had isolated the patient’s Coronary Sinus but hadn’t worked on his LAA.

Before the live case, Dr. Horton found that the patient had re-connection in one vein which he isolated before the live case demonstration began.

The Live Case: Mapping and Isolating the LAA

Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Dr. Horton used a mapping catheter in the Left Atrial Appendage (LAA).

To isolate the LAA, he used 40 watts radio frequency (RF) energy and a contact force sensing catheter with pressure readings above 10 but not higher than 25. The pressure readings indicate how hard the EP is pressing on the RF catheter to make a particular burn.

He discussed that if the LAA wasn’t contracting properly after the ablation, the patient would have to be on anticoagulation for life. (He, of course, discussed this possibility with the patient before the ablation.)

Dr. Horton rarely isolates the LAA during a first ablation unless he is absolutely sure it needs to be done. He stressed that the phrenic nerve often drops over the top of the LAA. For that reason, he doesn’t ablate too deep into the LAA but ablates at the base of the LAA. 

…he isolated the LAA and the Flutter disappeared as we watched.

Applause, Applause

There was excitement and clapping when he isolated the LAA and the Flutter disappeared as we watched.

Dr. Horton demonstrated for all the attendees that the LAA should also be mapped and isolated. And that isolating the LAA can be very effective in returning a patient to normal sinus rhythm.

Editor’s Comments:
No, no to Fluoroscopy: It’s a type of X-ray and its effect is cumulative. Therefore it should be avoided if possible. (Hence, the need for the staff to wear the lead aprons.)
Instead of fluoroscopy, Dr. Horton uses a non-radiation 3D imaging technique called Intracardiac Echocardiography (ICE), a form of ultrasound.
On a personal note, Dr. Horton has said that not having to wear those heavy lead aprons would probably add 5-10 years to his ablation career.
Importance of the LAA in Isolating A-Fib: More and more EPs are realizing how important the LAA is in mapping and isolating non-PV triggers. Many Master EPs after isolating the PVs, now go right to the LAA as their second isolation target.
What this means for patients: When selecting an EP for your catheter ablation, discuss the Left Atrial Appendage (LAA) as a possible site of non-PV A-Fib triggers. Ask your EP:
 “During my ablation, when you’re looking for non-PV triggers, will you also map and isolated the LAA, if necessary?” (You want an affirmative answer to your question.)

If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018

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2018 AF Symposium Live Case: RADAR―A Software Breakthrough in Identifying A-Fib Rotors and Drivers?

by Steve S. Ryan, PhD

RADAR’ may lead to the next big breakthrough in electro-magnetic imaging analysis software for mapping and ablating A-Fib rotors and drivers.

RADAR Clinical Trial

RADAR stands for Real-Time Electrogram Analysis for Drivers of AtRial Fibrillation.

The RADAR Clinical Trial is a prospective, non-randomized, investigational device exemption (IDE) study evaluating new analysis software in patients undergoing catheter ablation for persistent Atrial Fibrillation. This special software algorithm is made by AFTx, Inc.

A-Fib Pattern Recognition Algorithm

The software employs an A-Fib pattern recognition algorithm which can assess what is happening in a particular location within the heart. Then it geometrically stitches together the whole heart chamber to the highest available contact electrograms which results in a high-density 3-D map of the atrium in A-Fib.

Dr. Vivek Reddy from Mount Sinai, New York City, calls the resulting map a ‘PADA’ (probabilistic atrial driver assessment) map showing rotors and focal impulse areas.

The Live Case Using the AFTx RADAR System

Petr Neuzil, MD

Dr. Reddy introduced Dr. Petr Neuzil from Prague, Czech Republic who performed the live case.

Patient Background: The patient was in paroxysmal A-Fib but had suffered a stroke in November 2017 and was on anticoagulants.

First, a standard PVI was performed. Then the spiral mapping catheter was used to map and ablate non-PV triggers (using the Abbott EnSite Precision™ cardiac mapping system).

The AFTx RADAR system uses a 20-pole spiral multielectrode mapping catheter within the heart. (In contrast, the recently developed ECGi CardioInsight [Medtronic] uses a multielectrode vest to capture ECG far-field signals from the body surface.)

Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Lesion Indicators: Green, Blue and Red Dots

While watching the live case, when an effective transmural ablation was completed, a green dot appeared. After several ablation applications, a line appeared to connect the green dots. This apparently made it much easier to assess contiguous lesions.

A blue dot represented the latest ablation point. A red dot indicated a possible non-transmural lesion.

Dr. Neuzil’s surgical team in Prague was still ablating the patient when the time block for the live case ran out.

Editor’s Comments:
Making continuous lesions is critical to an effective ablation. But first the ablation sites must be accurately identified and mapped.
Easier and More Reliable: Not only does the RADAR system produce a very accurate, highest density map of the atrium, but the green dots and the visible line between them makes it much easier and more reliable to assess whether lesions are contiguous (no gaps).
History Being Made? Here is yet another instance where attendees at the AF Symposium 2018 were possibly seeing history being made.
The RADAR system may be the next big breakthrough in mapping and ablating A-Fib rotors and drivers and may be a major advance in the treatment of A-Fib.

If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018

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2018 AF Symposium Live Case: The DV8 Esophageal Retractor

Background: An esophageal atrial fistula is a very rare (about one in 2,000 cases) but often deadly complication. During a catheter ablation, the esophagus, which rests next to the heart, can be injured when heat from the catheter irritates it. The thermal damage can appear 2-3 weeks after the ablation when a hole forms between the atrium and the esophagus. This weakened area of the esophagus can be eaten through by acid reflex with deadly consequences.
Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Demonstrated during a live presentation via streaming video, the DV8 Retractor from Manual Surgical Sciences could eliminate the danger of esophageal atrial fistula. The DV8 Retractor is an inflatable balloon retractor system that moves the esophagus away from the site of ablation.

Drs. Kevin Heist, Conor Barrett and Moussa Mansour from Massachusetts General in Boston, MA demonstrated this simple, effective way of protecting the Esophagus from thermal injury during an ablation.

We watched as Dr. Heist and his colleagues inserted what looked like a thin straight silicon tube into the patient’s esophagus. (The esophagus is a flexible structure and moves naturally.) They then inflated the device which formed a bend or loop and pushed the esophagus as much as 40 mm away from the ablation site. The device could also be maneuvered up and down to further increase the deflection from the ablation site.

DV8 Retractor from Manual Surgical Sciences : Uninflated (L), Inflated (R).

The device has two ports―one for balloon inflation/deflation and a separate one for contrast injection into the esophagus to check placement.

Dr. Mansour stressed that this device should be used in all ablations. Even though esophageal fistula is a very rare complication (around one in 2,000 cases), there is now no reason for the esophagus to ever be damaged during an ablation.

Editor’s comments: Unfortunately there is no way to require EPs to learn about and used this device.
What this means to patients: If you are having an ablation, make sure your center and EP have and use this or another esophageal protection device. If they don’t, you shouldn’t proceed. You MUST go elsewhere where they do!!! It makes no sense to risk an esophageal injury when it is so easily prevented.

If you find any errors on this page, email us. Y Last updated: Saturday, February 24, 2018

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2018 AF Symposium Debate: ‘Can Anticoagulants be Stopped after AF Ablation?’

A topic of great interest to A-Fib patients. An interesting debate between Dr. Francis Marchlinski of the Un. of Pennsylvania Health Center in Philadelphia, PA and Dr. Elaine M. Hylek of Boston Un. Medical Center.

“Can Anticoagulants be Stopped after AF Ablation?”

• Dr. Francis Marchlinski took the “Yes” position (anticoagulation can be stopped).
• Dr. Elaine M. Hylek took the “No” position (anticoagulation should not be stopped).

(Though labeled a “debate”, there was no debate winner or loser; It was a more dramatic way of presenting different views on ablation.)

Dr. Marchlinski began by describing what he hears from patients, that they don’t want to be on anticoagulants. They ask me, “Doc, would you use anticoagulation if I didn’t have A-Fib? Because I’m telling you, I’m not having Atrial Fibrillation.”

In general, he said patients don’t want to have to take anticoagulants, especially after a successful ablation when they are A-Fib free. They are reluctant to take anticoagulation in the absence of EKG and other methods of monitoring when combined with no symptoms of A-Fib.

Pro: Stop Anticoagulation after Ablation

Dr. Marchlinski spoke first in favor of stopping anticoagulation. He anticipated several points that Dr. Hylek might argue, then added his response. ‘Dr. Hylek might say’…

• …there are no randomized studies proving that anticoagulation can be safely stopped after a successful ablation. True, he said. (Later in the debate, he and Dr. Hylek both agreed on this point.)

• …there are some observational studies and registries that indicate there is a high risk of stroke when stopping anticoagulation after an ablation. He countered by pointing out that many of these studies included patients who still had A-Fib after their ablation. …Continue reading this report->

2018 AF Symposium: A Friendly Debate “Can Anticoagulants Be Stopped After AF Ablation?”

by Steve Ryan

An especially interesting presentation at the 2018 AF Symposium was a friendly debate between Dr. Francis Marchlinski of the Un. of Pennsylvania Health Center in Philadelphia, PA and Dr. Elaine M. Hylek of Boston Un. Medical Center. This is a topic of great interest to A-Fib patients:

 “Can Anticoagulants be Stopped after AF Ablation?”

• Dr. Francis Marchlinski took the “Yes” position (anticoagulation can be stopped).
• Dr. Elaine M. Hylek took the “No” position (anticoagulation should not be stopped).

Though labeled a friendly “debate”, there was no debate winner or loser; It was a more dramatic way of presenting different views on anticoagulation and ablation.

Dr. Marchlinski described what he hears from patients, that they don’t want to be on anticoagulants. They ask me, “Doc, would you use anticoagulation if I didn’t have A-Fib? Because I’m telling you, I’m not having Atrial Fibrillation.”

In general, he said patients don’t want to have to take anticoagulants, especially after a successful ablation when they are A-Fib free. They are reluctant to take anticoagulation in the absence of EKG and other methods of monitoring when combined with no symptoms of A-Fib.

Note: Usually the first person in a debate is at a disadvantage. But Dr. Marchlinski instead anticipated what points Dr. Hylek would make and addressed them in his presentation.

Pro: Stop Anticoagulation after Ablation

Francis Marchlinski, MD

Dr. Marchlinski spoke in favor of stopping anticoagulation. He anticipated several points that Dr. Hylek might argue, then added his response. ‘Dr. Hylek might say’…

• …there are no randomized studies proving that anticoagulation can be safely stopped after a successful ablation. True, he said. (Later in the debate, he and Dr. Hylek both agreed on this point.)

• …there are some observational studies and registries that indicate there is a high risk of stroke when stopping anticoagulation after an ablation. He countered by pointing out that many of these studies included patients who still had A-Fib after their ablation.

• …every ablation has recurrences of A-Fib. He said, not in his practice. And in general, this is simply not true. A-Fib ablation has improved significantly over the years.

• …recurrences can be asymptomatic. True, so he trains his patients to use pulse assessment and other methods to check for heartbeat irregularities, and if found, to get in touch with his office. He pointed out that the field of monitoring and the increased variety of monitors available makes it less likely that long periods of A-Fib will go unnoticed.

• …A-Fib is a marker for more serious heart remodeling problems like cardiomyopathy, enlarged left atrium, inadequate left atrial contraction, etc. and therefore patients should be on anticoagulants. He countered by describing how carefully he and most other EPs examine a patient’s heart before, during and after an ablation. If any patient has any serious underlying heart problem, they are monitored life-long and are often on anticoagulants for life.

• He described using NOACs as a pill-in-the-pocket in certain cases when a patient has a recurrence, so that the patient doesn’t have to be on anticoagulants all the time.

• Bleeding risk is still significant, he noted, although the NOACs in general tested better than warfarin.

Con: Continue Anticoagulation after Ablation

Elaine M Hylek, MD

Dr. Hylek stressed that anticoagulation should not be stopped after an ablation. Her main points were:

• There is no way to reliably predict recurrences of A-Fib after an ablation. She encouraged the development of a predictive model.

• Pulse assessment is not reliable. Too many patients can’t recognize ectopic beats, for example.

• She discussed how serious heart remodeling problems can underlie A-Fib, and that these can cause strokes.

• Current monitoring is variable and unreliable. We need larger studies to improve this field.

• She cited a study of what she called “wake up strokes” where a patient wakes up in the morning and has suffered a stroke. By then it’s usually too late to be of much help. She indicated that 25% of strokes are these “wake up strokes.” She stressed how EPs need to do sleep apnea studies on A-Fib patients. [Many centers in the U.S. now automatically send anyone with A-Fib to a sleep apnea center for a study.]

Note: Though labeled a friendly “debate”, there was no debate winner or loser; It was just a more dramatic way of presenting different views on taking anticoagulants and catheter ablation.
Editor’s Comments:
(Just between you and me, I think Dr. Marchlinski won the debate.)
Patients don’t want to take anticoagulants after a successful ablation: The most telling point Dr. Marchlinski made was describing how most patients don’t want to take anticoagulants, especially after a successful ablation. In fact, one of the reasons patients have an ablation is to no longer have to take anticoagulants (and all the other A-Fib drugs which have so many bad side effects and long-term consequences.)
Recurrences are decreasing as ablation improves: With the use of contact force sensor catheters, Cryo and Laser Balloon ablation, advanced mapping techniques, etc., recurrence of A-Fib after an ablation has decreased significantly.
A-Fib patients aren’t dumb and can learn to take their pulse: Most patients are smart enough to take their own pulse or use today’s portable DIY monitors to tell if they are in A-Fib.
Anticoagulants are high risk drugs: Dr. Hylek didn’t discuss the dangers or acknowledge that anticoagulants are high risk drugs which can cause bleeding problems. For more about how NOACs dosage levels may also need to monitored, see the posted article: New Oral Anticoagulants Can Require Careful Dosing Too on the AFA discussion page.

Disclosures: Dr. Hylek lists in her disclosure statement extensive ties to the pharmaceutical industry; Dr. Marchlinski lists ties to medical device makers.

If you find any errors on this page, email us. Y Last updated: Wednesday, February 21, 2018

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2018 AF Symposium: The Innovative iCLAS Cyro Catheter

My first report from the 2018 International AF Symposium is about an innovative, ultra-low temperature Cryo catheter, the iCLAS catheter from Adagio Medical.

Various positions possible with the iCLAS catheter from Adagio Medical

I knew it was something special by the incredibly high-powered, renowned presenters: two of the most important people in the treatment of Atrial Fibrillation―Dr. James Cox of the original Cox Maze operation and Prof. Michel Haissaguerre of the original PVI catheter ablation.

One Catheter. Unlimited Shapes.

The iCLAS catheter is a Cryo catheter that uses ultra-low temperatures and is unlike anything currently on the market. The catheter can be manipulated into many different configurations depending on the lesions which need to be made.

When I visited the Adagio booth, it was fascinating to see how easily the catheter could be designed into unlimited profiles.

Using its full length, the catheter can produce ultra low temperatures along its whole span (110mm). It has 20 electrodes which can also produce cryo-mapping of the atria.

For Flutter Ablations in the Caviotricuspid Isthmus in the right atrium, a shorter catheter is used … continue reading my report–>.

2018 AF Symposium: Innovative iCLAS Cyro Catheter by Adagio Medical

by Steve S. Ryan, PhD.

I knew it was something special by the incredibly high-powered, renowned presenters: two of the most important people in the treatment of Atrial Fibrillation―Dr. James Cox of the original Cox Maze operation and Prof. Michel Haissaguerre of the original PVI catheter ablation.

iCLAS Cryo ablation catheter hand graphic at A-Fib.com

iCLAS catheter (Continuous Lesion Ablation System) by Adagio Medical

One of the most fascinating presentations at the Product Theatre on Friday, January 12, was about the innovative, ultra-low temperature iCLAS catheter. Dr. Hugh Calkins of Johns Hopkins was the session moderator. The panel of presenters were:

James Cox of NW Feinberg Sch. of Medicine in Chicago, IL
Professor Michel Haissaguerre of the Bordeaux LIRYC group
Tom de Potter of the Cardiovascular Center in Aalst, Belgium
Lucas Boersma of AMC/U. of Amsterdam, The Netherlands
Alex Babkin, Chief Technical Officer of Adagio Medical

One Catheter. Unlimited Shapes.

Examples of the many different configurations of the iCLAS

The iCLAS catheter is a Cryo catheter that uses ultra-low temperatures and is unlike anything currently on the market. The catheter can be manipulated into many different configurations depending on the lesions which need to be made.

When I visited the Adagio booth, it was fascinating to see how easily the catheter could be designed into unlimited profiles.

Using its full length, the catheter can produce ultra low temperatures along its whole span (110mm). It has 20 electrodes which can also produce cryo-mapping of the atria.

For Flutter Ablations in the Caviotricuspid Isthmus in the right atrium, a shorter catheter is used with a continuous length of 54mm. It can also do Focal Tip Ablations. (The temperatures are so cold they use a heating balloon in the esophagus to prevent any damage.)

About Adagio Medical, Inc.: It’s a privately held medical device company founded in 2011 by Dr. James Cox and Mr. Olav Bergheim. It uses liquid nitrogen to produce ultra-low temperature lesions and developed Near Critical Nitrogen (NCN) technology which permits liquid nitrogen to be used in catheters inside the heart.

VIDEO Animation: iCLAS Catheter by Adagio Medical

Check out this excellent animation of the ultra-low temperature iCLAS catheter. With titles and music, illustrates examples of the creation of long and continuous lesions with full transmurality via endocardial approach with small size catheters (≤9Fr). (1:45) Produced by Adagio Medical, Inc.

YouTube video playback controls: When watching this video, you have several playback options. Settings (speed/quality) are located in the lower right portion of the frame, along with the option to enlarge video to full frame. 

Editor’s Comments:
Why is the iCLAS Cryo catheter special and innovative? The iCLAS catheter produces ablation lesions like current CryoBalloon catheters but at lower temperatures (colder). One would expect that such ultra-low Cryo lesions would be deeper, more transmural, and more lasting. In addition, the ability to produce unlimited shapes gives the iCLAS catheter a unique ability to position Cryo lesions in a variety of locations in the heart. It will make ablations much simpler and easier for EPs.
Historical! Attendees at this AF Symposium presentation were amazed and astounded by the possibilities of the iCLAS system. Endorsed by Dr. James Cox and Prof. Michel Haissaguerre, it was a historical breakthrough moment that few present will ever forget.
Next Great Breakthrough in Treating A-Fib! The iCLAS ultra-low temperature catheter with its unique ability to configure in unlimited shapes is the next great breakthrough in treating A-Fib! Barring any unforeseen problems with approval by the FDA, it will become the treatment of choice for ablating A-Fib/Flutter. (You heard it here first, folks!)

If you find any errors on this page, email us. Y Last updated: Wednesday, February 28, 2018

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2018 International AF Symposium: My First Report

Held Jan. 11-13, 2018 in Orlando, FL, the annual International AF Symposium is an intensive and highly focused three-day scientific forum which brings together the world’s leading medical scientists, researchers, cardiologists and electrophysiologists to share the most recent advances in the treatment of atrial fibrillation.

The 45 distinguished faculty were leaders in the Atrial Fibrillation field from around the world (the U.S., England, Canada, France, Italy, Germany, Switzerland, Ireland, The Netherlands, Russia, Taiwan, South Korea, the Czech Republic, and two members of the U.S. FDA [Food and Drug Administration].

I made it to every presentation despite being sick with some kind of a virus I caught on the plane to Orlando. I was running on fumes.

Hot Topics

KISS OF DEATH FOR FIRM?

In a late-breaking presentation, the interim results of REAFFIRM trial were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center. The success rate for PVI plus FIRM was not significantly different (78%) for patients receiving only a standard PVI (70%).

Barring further research, this may mean the end of the FIRM system as an effective player in A-Fib ablation. See my upcoming report for more.

FOCUS ON LEFT ATRIAL APPENDAGE

Like last year, there was great interest in and examination of the importance of the Left Atrial Appendage (LAA). Four of the six live case presentations dealt with the LAA. Ten of the more than 62 presentations focused on the LAA.

…To continue reading… Go to My Overview of the 2018 International AF Symposium->

Jeremy Ruskin, MD, Mass. General Hospital and AF Symposium

Dr. Ruskin

“Steve Ryan’s summaries of the A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation.” — Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

2018 AF Symposium: Reports for Patients by Steve S. Ryan, PhD

AF Symposium 2018

My Summary Reports Written for A-Fib Patients

by Steve S. Ryan, PhD

The annual AF Symposium is one of the most important scientific conferences on A-Fib in the world. I attend to learn about advances in research and treatments directly from the most eminent scientists and doctors. 

My goal is to offer A-Fib.com readers the most up-to-date research and developments that may impact their treatment choices.

REPORT TITLE PRESENTER (S) DATE POSTED
11. Findings from the CASTLE-AF Clinical Trial Dr. Nassir Marrouche Mar. 21, 2018
10. Live Case: CryoBalloon Catheter for Isolation of the LAA Dr. Bradley Knight from Northwestern Un. in Chicago, IL Mar. 1, 2018
9. REAFFIRM Trial—Kiss of Death for FIRM Mapping? Dr. John Hummel from the Ohio State University Wexner Medical Center Feb. 28, 2018
8. Live Case: Installing an Amplatzer™ Amulet™ LAA Occluder Dr. Claudio Tondo from Milan, Italy Feb. 28, 2018
7. Live Case: Isolating the Left Atrial Appendage using RF Energy Dr. Rodney Horton, Texas Cardiac Arrhythmia Institute, Austin, TX Feb. 25, 2018
6. Live Case: RADAR―A Software Breakthrough in Identifying A-Fib Rotors and Drivers? Dr. Petr Neuzil from Prague, Czech Republic Feb. 24, 2018
5. Live Case: Installing a Coherex WaveCrest LAA Occlusion Device Dr. Tom De Potter from Aalst, Belgium Feb. 24, 2018
4. Live Case: The DV8 Retractor: an Esophageal Deviation Tool from Manual Surgical Sciences Drs. Kevin Heist, Conor Barrett and Moussa Mansour from Massachusetts General in Boston, MA Feb. 22, 2018
3. A Friendly Debate: “Can Anticoagulants Be Stopped After AF Ablation? Dr. Francis Marchlinsk, Un. of Pennsylvania Health Center and Dr. Elaine M. Hylek, Boston Un. Medical Center Feb. 21, 2018
2. New Product: Innovative iCLAS Cyro Catheter by Adagio Medical Hugh Calkins, MD moderator; Panelists: Drs. James Cox, Michel Haissaguerre, Tom de Potter, Lucas Boersm and Alex Babkin Feb. 7, 2018
1. 2018 AF Symposium Overview by Steve S. Ryan, PhD – – – Feb. 4, 2018
Archive: Link to my 2017 AF Symposium reports of all Atrial Fibrillation-related medical conferences

J. Ruskin

“Steve Ryan’s summaries of the A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation.” — Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

Return to AF Symposiums Summaries By Year

 If you find any errors on this page, email us. Y Last updated: Wednesday, March 21, 2018

2018 International AF Symposium: My Overview

By Steve S. Ryan, PhD

I made it to every presentation despite being sick with some kind of a virus I caught on the plane to Orlando. I was running on fumes.

The annual International AF Symposium is an intensive and highly focused three-day scientific forum which brings together the world’s leading medical scientists, researchers, cardiologists and electrophysiologists to share the most recent advances in the treatment of atrial fibrillation.

Long, Full Days: Held Jan. 11-13, 2018 in Orlando, the AF Symposium days started early each day at 7:00 am and were tightly scheduled with presentations which usually lasted till 5:30 or 6:00 pm (except for a shorter last day so attendees could catch a flight home).

Live Streaming Video: There were six live procedures presented via internet streaming video. This year they were scheduled throughout the days depending on what topic they related to. (Previously all the live cases were scheduled back-to-back in one morning.)

Networking: The generous breaks and lunches allowed attendees to interact with and visit the manufacturer’s exhibits to learn what’s new from the many vendors. I made a point of visiting each vendor.

AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

AF Symposium 5-floor-to-ceiling video monitors

Faculty and Feedback

The 45 distinguished faculty were leaders in the A-Fib field from around the world (the U.S., England, Canada, France, Italy, Germany, Switzerland, Ireland, The Netherlands, Russia, Taiwan, South Korea, the Czech Republic, and two members of the U.S. FDA [Food and Drug Administration].)

Interactive Feedback: Audience feedback was done this year through the Cloud. Presenters would pose multiple choice questions and invite each attendee to cast a vote. The vote tally would be flashed on the screen within seconds for further discussion.

The Venue: The Hyatt Regency in Orlando

Hyatt Regency Orlando, Fl

The Hyatt Regency is a magnificent, vast venue. One does a lot of walking to get back and forth from the presentations to the exhibit/lunch area. (For those concerned, bathrooms are scarce and not well situated.)

HOT TOPICS

Kiss of Death for FIRM?

In a late-breaking presentation, the interim results of REAFFIRM were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center. The success rate for PVI plus FIRM was not significantly different (78%) for patients receiving only a standard PVI (70%).

Barring further research, this may mean the end of the FIRM system as an effective player in A-Fib ablation. See my upcoming report for more.

Focus on Left Atrial Appendage

Like last year, there was great interest in and examination of the importance of the Left Atrial Appendage (LAA). Four of the six live case presentations dealt with the LAA. Ten of the more than 62 presentations focused on the LAA.

Live Cases via Streaming Video

Live Streaming Video from AF Symposium at A-Fib.comThere were six live video presentations (via internet streaming video) of procedures from centers around the world. The live cases came from these centers:

Prague, The Czech Republic: Na Homolce Hospital
Milan, Italy: University of Milan Centro Cardiologica Monzino
Boston, Massachusetts: Massachusetts General Hospital
Aalst, Belgium: Cardiovascular Center Aalst. OLV Hospital
Austin, TX: Texas Cardiac Arrhythmia Institute
Chicago, IL: Northwestern Memorial Hospital

The sheer technical complexity of producing these live video events is staggering. (As someone who worked in broadcast TV at NBC for many years, I was in awe at how well they pulled off these technological feats.) Each live case came off without a hitch and was integrated seamlessly into the topics and other presentations.

Topics and Agenda

The following general topics included several 15 minute presentations on each topic, followed by time for audience questions and discussions. 

The first presentations dealt with the “basic science” of A-Fib. Often this session provides new insights, advanced research and breakthrough findings.

Day 1, Thursday January 11

• Pathophysioloogy, Risk Factors and Genetics 
• Stroke Prevention in and Screening for Atrial Fibrillation
• Left Atrial Appendage Closure & Case Transmissions
• If I Had Permanent AF and Previous Intracranial Hemorrhage, I Would Choose? (Endocardial LAA Closure, Epicardial LAA Closure, or Apixaban (Eliquis) 5mg B.I.D.)
• Challenging Cases in AF Management I: Antiarrhythmic Drugs, Anticoagulation, and Clinical Decision Making

Day 2, Friday January 12

•  Physiology and Experimental Insights: Implications for AF Ablation
• Mechanism-Guided Ablation of Atrial Fibrillation and Case Transmissions
•  New Technologies, Late Breaking Trials, First Report Investigations in AF Ablation and Case Transmissions
•  New Technologies for AF Ablation (Continued)

Day 3, Saturday January 13

•  Clinical Trials, Guidelines and Regulatory Issues in AF Management
•  Evolving Strategies to Improve the Success and Safety of AF Ablation
• Challenging Cases in AF Management II: Catheter Ablation and Left Atrial Appendage Closure

Steve with Dr. Michele Haisaguerre, The French Bordeaux Group

Excellent Presentations But Attendance Discouraging

The presentations were excellent, as usual, and well coordinated by topics. Attendance this year was down (about 700 attendees vs. 1,000+). I heard that this was due to new financial regulations in Europe which prevented many from attending. The low attendance was surprising and, discouraging. Can the wonderful AF Symposium continue with such a reduced attendance?

As someone who has been attending the AF Symposium for 15 years, it’s unique and invaluable. It provides info and discussions on A-Fib unlike any other conferences. Each day one comes away with incredible insights into A-Fib.

Each day one comes away with incredible insights into A-Fib.

Why I Attend: Expect My Reports

It’s a privilege to be able to attend presentations by the best clinicians and researchers working in A-Fib today. I learn more in three days than in a year of reading the various A-Fib research reports.

I’m especially blessed by being able to ask questions of the presenters and dialogue with them.

I will share the current state of the art in A-Fib research and treatments. Look for my reports on what’s relevant to patients and their families. (I already have 8 reports to share.)

If you find any errors on this page, email us. Y Last updated: Wednesday, February 21, 2018

Back to 2018 AF Symposium Reports

Orlando, FL Here I Come—2018 International AF Symposium

When this gets posted, I’ll be on an 8 am flight from Los Angeles to Orlando. Upon arrival, I hope to pick up my 2018 AF Symposium registration badge and other materials before heading to my hotel for a good night’s sleep (the conference day starts at 7 am and continues into the early evening).

Three Intense Days to Come

The next 3 days will be intense and highly focused. More than 50 of the world’s leading medical scientists and cardiologists will make over 65 presentations, and participate in live procedures via video, and panel discussions. I listen intensively, take loads of notes, make audio recordings (with permission), renew friendships and make new contacts among the over 1,000 international attendees.

After the conference (often on my way home Saturday night), I select the presentations on topics of interest to readers of A-Fib.com.

Index to All the Atrial Fibrillation-Related Medical Conferences

Index to reports

In the meantime, you may want to browse my Index to all the Atrial Fibrillation-related medical conferences and symposiums I’ve reported on. You may find a topic of interest. (Or just type your topic into the ‘Search’ box in the upper right corner of every web page and you’ll get a list of results.) For now, go to Index: Steve’s Reports of Atrial Fibrillation Medical Conferences.

Look for my first, overview report soon after the conference.

Coming in January: The International AF Symposium 2018

To stay current about advances in the treatment of Atrial Fibrillation, each year I attend the annual International AF Symposium. This intensive, highly focused three-day symposium brings together more than 50 of the world’s leading medical scientists and cardiologists for a thorough and practical course on the current state of the art in the field of atrial fibrillation.

From January 11-13, 2018, I’ll be traveling to Orlando, FL, to attend and report on presentations at the 23rd Annual International AF Symposium at the Hyatt Regency.

I select the topics of most importance from a patient’s point of view and write summaries for my readers on A-Fib.com.

This meeting has become a major scientific forum for health care professionals to learn about advances in research and therapeutics directly from many of the most eminent researchers, scientists and investigators in the field.

As in years past, I usually attend most of the over 65 presentations, live procedures via video, and panel discussions.

Then I select the topics of most importance from a patient’s point of view and write summaries for my readers on A-Fib.com. Look for reports in the months following the symposium.

In the meantime, you may want to review my reports from the 2017 AF Symposium.

AF Symposium 2018 at A-Fib.com

AF Symposium 2018, Orlando, FL

My Summary Reports: California Heart Rhythm Symposium 2017

Held at the UCLA Luskin Conference Center in Los Angeles from November 17-18, the California Heart Rhythm Symposium is a regional symposium focused on the latest advances in the field of cardiac arrhythmias (Atrial Fibrillation and Ventricular Arrhythmias).

The one and one-half day Symposium was well attended and featured presentations by recognized leaders in the field. (I only attended the sessions on A-Fib.)  I attended as a journalist representing A-Fib.com.

The following are 15 brief descriptions of the presentations that made the most impression on me.

Recurrence Rates Have Improved

Dr. Greg Michaud from Vanderbilt described how recurrence rates have improved with the use of newer treatments such as contact force sensing catheters and CryoBalloon ablation (and the new Laser balloon). The focus now is where else to ablate besides the Pulmonary Veins (PVs). In his ablations Dr. Michaud tends to ablate or fill in the posterior wall with ablation burns.

“The focus now is where else to ablate besides the Pulmonary Veins (PVs).” Dr. Greg Michaud

A-Fib and Dementia

Dr. Jared Bunch of the Intermountain Heart Institute in Utah shocked the attendees with the statements: one in three of us will develop A-Fib in our lifetime; A-Fib doubles the risk of developing dementia; and Dementia has become the third leading cause of death in the U.S.

He also pointed out that being on warfarin causes microbleeds in the brain which increase dementia. The younger you are when you develop A-Fib, the more likely you are to develop dementia. (See my article A-Fib Doubles Risk of Dementia.) But a catheter ablation reduces the risk of developing dementia to that of a normal person.

“…when he went into A-Fib, he lost the ability to speak because he was in dementia. Dr. Jared Bunch”

Dr. Bunch gave the striking example of a patient who would speak normally when in sinus rhythm. But when he went into A-Fib, he lost the ability to speak because he was in dementia.

Ablating LAA Increases Ablation Success Rate

Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute in Austin, TX, described his current ablation strategy. Of special note, he showed how ablating the Left Atrial Appendage (LAA) increases ablation success rates. During an ablation, he also concentrates on the posterior wall between the PVs. He also pointed out there is currently no standard, agreed-upon protocol for mapping and ablating non-PV triggers.

Contact Force Sensing Catheters & CryoBalloon Ablation

“Contact force sensing catheters have lower recurrence levels.” Dr. Jocob Koruth

Dr. Jocob Koruth of Mount Sinai Medical Center in New York described how contact force sensing catheters have lower recurrence levels. But CryoBalloon ablations seem more durable. He mentioned that the FIRM and CardioInsight ECGI vest systems have not been proven.

Editor’s Comments: The FIRM system has received a good deal of negative press and research papers. See Firm Mapping System  and FIRM Research.  But the CardioInsight ECGI vest system, though very new, seems to have great potential.

Flutter As Risky as A-Fib

Dr. Kim Rajappan from Oxford University in Oxford, UK discussed A-Fib and A-Flutter. Both carry the same risks for patients. Rate control is harder for Flutter. Most EPs would do a Flutter ablation even if the patient were not in A-Fib at the same time.

Editor’s Comments: Flutter can be considered as a milder or more organized form of A-Fib. It may feel slightly better than A-Fib and be better tolerated. But it’s still as dangerous as A-Fib.

Importance of Isolating the LAA

“… the importance of measuring flow velocity out of the LAA after isolating it.” Dr. Luigi Di Biase

Dr. Luigi Di Biase of the Albert Einstein College of Medicine in New York echoed Dr. Natale in stressing the importance of the LAA (Left Atrial Appendage) in A-Fib. But he also pointed out the importance of measuring flow velocity out of the LAA after isolating it. If LAA flow velocity is low, it’s necessary to keep a patient on anticoagulants for life or remove the LAA such as by using the lariat device. … Continue reading this report…->

Increasing Your Quality of Life: Catheter Ablation versus A-Fib Drugs

When seeking your Atrial Fibrillation cure, you’re often faced with the choices of catheter ablation versus antiarrhythmic drugs therapy.

We know from previous research studies that it’s safer to have an ablation versus living a life on antiarrhythmic drug therapy (AAD). (See Ablation Safer Than Life on Antiarrhythmic Drugs.)

But how do the two treatments compare when it comes to improvement in general health and ‘quality of life’?

Measuring ‘Quality of Life’

To determine success after treatment, researchers traditionally measure if A-Fib recurs using periodic ECGs. But this is “hardly a measure of successful treatment”, says Dr. Carina Blomstrom-Lundqvist, principal CAPTAF investigator from Uppsala University in Sweden.

CAPTAF stands for ‘Catheter Ablation compared with Pharmacological Therapy for Atrial Fibrillation‘.

The CAPTAF clinical trial is one of the first studies in which improvement in ‘quality of life’ was the goal. The trial compared the Atrial Fibrillation treatment effects of ablation versus antiarrhythmic drugs.

One-year results were presented in August at the 2017 European Society of Cardiology (ESC) Congress.

The CAPTAF Clinical Study

The CAPTAF trial enrolled 155 symptomatic patients with paroxysmal or persistent A-Fib at four Swedish centers and at one center in Finland.

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

A-Fib Drug Therapies

All enrolled patients had to have failed one drug therapy (rate or rhythm control). The average age of the enrolled patients was 56 years. Nearly three-quarters had paroxysmal A-Fib. On average they had been diagnosed with A-Fib for about 5 years, and 70%-80% of the patients had severe or disabling symptoms.

Catheter ablation (RF)

Patients received a subcutaneously implantable cardiac monitor 2-m onths prior to the start of the study (to establish a baseline ‘burden’ of A-Fib, i.e. the proportion of time in A-Fib). Then participants were randomized to ablation with pulmonary vein isolation or antiarrhythmic drug therapy. (The study protocol required patients randomized to the ablation regimen to be completely off antiarrhythmic drugs by 6 months after their ablation procedure.)

The primary goal of the study was a change in general health-related quality of life.

CAPTAF Results: Overall Health & ‘Quality of Life’ Improved More after Ablation

Overall Health: After 12 months of follow-up, the ablation group showed a greater improvement in average overall health by 11.0 points versus 3.1 points improvement in the drug group (as measured by a standard survey instrument). The 8-point difference in gain between the two groups was statistically significant.

Quality of Life: The quality-of-life domains (general health, physical function, mental health, role-emotional, role-physical, and vitality) improved significantly more in the ablation group than in the drug group. No significant differences were shown in the remaining two domains (bodily pain and social functioning).

AF Burden: The AF burden of the ablation group was decreased by an average of 20% points versus 12% points among the group on antiarrhythmic drugs. The change from baseline did not reach statistical significance between treatment groups.

The complication rates were comparable between treatment groups.

Summarizing the Results

About the difference in quality of life, Dr. Carina Bloomstrom-Lindqvist, principal CAPTAF investigator, explained that continued treatment with an antiarrhythmic drug in the drug group of patients compared with no drug treatment in the ablated patients “is absolutely the explanation” for the observed difference in quality of life.

Regarding her findings, she said, “Using quality of life as the primary endpoint of a trial for the first time, we demonstrated that pulmonary vein isolation [PVI] is significantly more effective than antiarrhythmic drugs…even at an early stage of their disease.”

Want a Better Quality of Life? Get a Catheter Ablation

“Using quality of life as the primary endpoint…PVI is significantly more effective than antiarrhythmic drugs…”

The CAPTAF clinical study, though small, goes much further than previous studies and is a significant milestone for Atrial Fibrillation patients. This was one of the first studies to focus on quality of life after treatment.

The CAPTAF results prove scientifically that ablation works better for A-Fib patients than antiarrhythmic drugs (AADs).

If you have A-Fib and want to improve your quality of life―get a catheter ablation. It makes you feel better than a life on antiarrhythmic drugs.

Remember: Seek your Cure!
Anyone no longer in A-Fib can tell you how wonderful it is
to have a heart that beats normally again.

Resources for this Article
Blomstrom-Lundqvist, Carina. Ablation of Atrial Fibrillation Improves Quality of Life More Than Drugs (CAPTAF). Presentation. ESC Congress, August 2017.

Zoler, M.  A Fib ablation surpasses drugs for improving quality of life. Cardiology News, Aug 30, 2017 URL: http://www.mdedge.com/ecardiologynews/article/145764/arrhythmias-ep/fib-ablation-surpasses-drugs-improving-quality-life

Ablation of atrial fibrillation improves quality of life more than drugs (CAPTAF). Press release. European Society of Cardiologists. Aug 29, 2017. URL: https://www.escardio.org/The-ESC/Press-Office/Press-releases/ablation-of-atrial-fibrillation-improves-quality-of-life-more-than-drugs-captaf

ESC 2017: Ablation of Atrial Fibrillation Improves Quality of Life More than Drugs – CAPTAF Trial Sept 4, 2017. URL: http://www.practiceupdate.com/content/esc-2017-ablation-of-atrial-fibrillation-improves-quality-of-life-more-than-drugs-captaf-trial/57590

 

CASTLE AF Study: Live Longer―Have a Catheter Ablation!

Catheter ablation actually reduces death rates and hospital admissions. That’s the finding in the CASTLE AF trial, a key heart disease study, by Dr. Nassir Marrouche and his colleagues.

In a presentation at the 2017 European Cardiology Congress in Barcelona, Spain, Dr. Marrouche described CASTLE-AF study participants as having A-Fib, advanced heart failure (i.e. low ejection fraction) and an Implantable Cardioverter Defibrillator (ICD).

The multicenter CASTLE-AF trial focused on patients with A-Fib and systolic heart failure.

The CASTLE-AF trial enrolled 398 patients in 33 sites across Europe, Australia and the US between 2008 and 2016. Patients were randomized to receive either radiofrequency catheter ablation or conventional drug treatment.

The study set out to definitively test the ability of A-Fib ablation to improve hard outcomes in patients with symptomatic paroxysmal or persistent A-Fib and a left ventricular ejection fraction (LVEF) of ≤35 percent (dangerously low percent). Median follow-up period was 37.8 months.

Results: Ablation Improves Quantity Not Just the Quality of Life

After catheter ablation, the death rate of trial patients was lowered by an amazing 47%! This is a lot better result than research studies using ICDs with drug therapy to lower the death rate in similar patients.

Before this study, catheter ablation was known to improve quality of life, but in this study it also improved life outcomes (the quantity of life, how long one lives).

In addition, there may be a “major impact” on reducing costs associated with hospitalizations.

Ablation Improves Ejection Fraction

Once we study the soon-to-be published CASTLE-AF results, we can document what we’ve often observed anecdotally, that catheter ablation improves lower-than-normal ejection fraction and consequently cures a major component of heart failure.

Dr. Marrouche recommends EPs treating heart failure patients with A-Fib to “ablate them early on, very soon in the disease stage.”

My Anecdotal Evidence: Just last month I advised a 73-year-old man in persistent A-Fib to have an ablation by Dr. Andrea Natale. After only one month in sinus, his ejection fraction improved from a low 35% to a normal 55% (normal range is 50 to 75 percent)!

The CASTLE-AF study could pave the way for wider adoption of catheter ablation for treatment of A-Fib.

Even though he’s only a month into his blanking period, he feels terrific.

Wider Adoption of Catheter Ablation?

The CASTLE-AF study results could be a game changer for Atrial Fibrillation patients! Results could pave the way for wider adoption of catheter ablation and may prompt changes in current guidelines for treatment.

CASTLE-AF stands for Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation

Resources for this Article
Marrouche, Nassir. Castle AF: Catheter Ablation vs. Conventional Therapy for Patients with A-Fib and LV Dysfunction. Presentation at the 2017 European Society of Cardiology (ESC) Congress. August 27, 2017.

CASTLE-AF: Catheter Ablation vs. Conventional Therapy for Patients with AFib and LV Dysfunction. American College of Cardiology (acc.org). Aug 27, 2017. URL: http://www.acc.org/latest-in-cardiology/articles/2017/08/16/13/24/sun11am-castle-af-catheter-ablation-conventional-therapy-patients-afib-lv-dysfunction-esc-2017

CASTLE-AF Study Results Indicate Catheter Ablation of Atrial Fibrillation as First-Line Treatment for Heart Failure Patients. Biotronik Pulsar Press Release. Distributed by Pressebox.com. Aug 28, 2017. URL: https://www.pressebox.com/pressrelease/biotronik-se-co-kg/CASTLE-AF-Study-Results-Indicate-Catheter-Ablation-of-Atrial-Fibrillation-as-First-Line-Treatment-for-Heart-Failure-Patients/boxid/868578

Genetics of A-Fib—40% Increased Risk of Developing A-Fib If Relative Has It

AF Symposium 2012

Summary by Steve S. Ryan, PhD, January 2012

Patrick Ellinor, MD

Patrick Ellinor,

Genetics of A-Fib—40% Increased Risk of Developing A-Fib If Relative Has It

Genetic research in A-Fib, though in its preliminary stages, has the potential to be a game changer for patients with A-Fib. Dr. Patrick Ellinor of Mass General, Boston gave a presentation on the “Genetics of A-Fib: How Will We Translate GWAS Findings to Clinical Practice?”

A-Fib Is Inheritable

“If you have any immediate family with A-Fib, you have a 40% increased risk of developing A-Fib yourself. And the younger that someone in your family gets A-Fib, the more likely you are to have A-Fib.”

Screen for A-Fib?

If someone has A-Fib, should all their immediate family members be screened for A-Fib? Since in the US alone over three million people have A-Fib, it isn’t possible or practical to screen all family members for A-Fib. And even if we could screen everyone, we don’t yet have the means to prevent A-Fib from developing or even to identify patients with pre-A-Fib.

Editor’s Comments: If anyone in your immediate family has A-Fib, you are very likely to develop A-Fib yourself. You have to be more aware and vigilant than the average person. If, for example, you feel palpitations or a racing heart rate, take it very seriously. Don’t hesitate or delay in going to an Electrophysiologist (EP) to have yourself checked out. Make sure you tell your EP or Cardiologist that your relative has A-Fib.

Specific Genetic Chromosomes Associated With A-Fib

Dr. Ellinor identified the specific genetic chromosomes currently found to be associated with A-Fib:

  • 1q21
  • 16q22
  • and particularly 4q25

People with a particular combination of 3 genetic variants on chromosome 4q25 are six times more likely to develop A-Fib.

Further Research Needed

But current research has only revealed “associations.” Further research is needed to determine:

  1. Are these chromosomes associated with and/or do they cause an increased risk of A-Fib stroke, heart failure and death?
  2. Are these genetic variants associated with or do they indicate that a certain treatment should be used or that a certain outcome is more likely?
  3. How important are these genetic variants in the development of A-Fib?
  4. How do these genetic variants affect what types of arrhythmia develop? Do Paroxysmal A-Fib, Permanent A-Fib, or A-Flutter have different genetic profiles?
  5. And most importantly, how do these genetic variants work? What Is the mechanism behind the association?

“Right now all we have is an association.” “We don’t have a fundamental understanding as to how the variants themselves lead to the (A-Fib) disease.”

Warn all Your Immediate Family Members

If you have A-Fib, you must warn all your immediate family members that they have a good chance of getting it also. Even though we don’t know yet how to definitively prevent A-Fib, there are some precautions your family members can take:
  1. Avoid binge drinking and heavy partying.
  2. Avoid antihistamines and anything that can stimulate or trigger A-Fib. (see A-Fib Triggers) (This doesn’t necessarily include coffee. Some research indicates coffee may prevent A-Fib.)
  3. Be more attentive to overall health. Obesity, for example, is often a contributing factor to A-Fib. Sleep apnea is known to lead to A-Fib.
  4. Check for deficiencies in essential minerals (electrolytes) like magnesium or potassium? Are calcium levels too high (which may be a trigger for A-Fib)?
  5. Avoid or learn to cope with stress (not always possible).
    There is a tendency in all of us to not tell others if we are ill, perhaps because we perceive it as somewhat humiliating and a weakness in ourselves. But no one should be ashamed of having A-Fib. Most likely it isn’t anything we brought on ourselves. It’s genetic! It’s nobody’s fault!

We are not being fair to our family members by not telling them about our A-Fib. Don’t just mention it in passing. Sit down with them and tell them what A-Fib is like, and that they are at risk.

If you love your family, you owe it to them. This applies particularly to your brothers and sisters with whom you may have a loving but somewhat competitive relationship. Anyone in your immediate family must be warned.

If you find any errors on this page, email us. Y Last updated: Monday, May 1, 2017

Back to: 2012 AF Symposium

2017 AF Symposium: FIRM Rotor Mapping System During Live Ablation

Dr David Wilber Loyola University

D. Wilber

In a live case from the 2017 AF Symposium, Dr. David Wilber from Loyola University Medical Center showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. (‘FIRM’ stands for Focal Impulse and Rotor Modulation.)

Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation…Continue reading my report.

2017 AF Symposium: Live Case of Ablation with FIRM Mapping System

Dr David Wilber Loyola University

D. Wilber, MD

In a live case, Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. ‘FIRM’ stands for Focal Impulse and Rotor Modulation.

Patient background: The patient was a 54-year-old male in persistent A-Fib for 7 months, obese with a BMI of 31, hypertension, diabetes, and obstructive sleep apnea. He was symptomatic, with fatigue and decreased exercise tolerance. An MRI showed his Left Atrium was 15.5% fibrotic. (If using Dr. Nassir Marrouche’s Utah I–IV Classification System to rate the patient’s amount of fibrosis, this patient would be “Utah Stage 2”, i.e. a reasonable candidate for a catheter ablation.)

Voltage & FIRM Mapping: Rotors Ablated First

FIRM mapping display of left atrial rotor during atrial fibrillation.

FIRM mapping display of left atrial rotor during atrial fibrillation.

In live video streaming from Chicago, Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation (PVI).

He explained that the concept of terminating A-Fib during a PVI ablation doesn’t work with the FIRM system. Instead, he looks to ablate rotational areas (which are usually 2.2 cm across). He does this by using a Contact Force sensing catheter usually at 35 watts for 30 sec.

During this ablation, he found one rotor at the base of the Left Atrial Appendage (LAA). (In the followup panel discussion, Dr. Andrea Natale commented that he and his colleagues now look first for A-Fib signals in the LAA.)

FIRM Rotors Hard to See

VIDEO examples: Dr. Wilber showed a video using FIRM in which [even to my untrained eye] it was easy to see a rotor. But he showed other videos where the overlapping, swirling waves made it difficult to see where exactly a rotor was coming from.

Editor’s Comments:
This patient was at great risk of recurrence after a catheter ablation, because of his various illnesses (comorbidities). By restoring him to normal sinus rhythm, he would be able to exercise and develop life-changing habits to reduce his obesity, diabetes, and hypertension.
ECGI CardioInsight system: Focal and re-entrant driver maps

ECGI CardioInsight system: Focal and re-entrant driver maps

Abbott Topera FIRM vs Medtronic ECGI CardioInsight:  In comparison to the ECGI CardioInsight system where the rotors and focal sources are very obvious (even to untrained observers), the FIRM system display of rotors are often confusing and hard to identify. Dr. Wilber acknowledged that it takes study and experience with the FIRM system to use it effectively.
To me, the Abbott Topera FIRM system seems hard to use. In head-to-head competition with the Medtronic ECGI CardioInsight system, I predict the FIRM system will probably not survive.
The Medtronic ECGI CardioInsight system has been in limited use in Europe and in 2017 has begun a limited rollout in the U.S.

For more on the Medtronic ECGI CardioInsight, see my article: ECGI Mapping Now Available in U.S.

For more about Dr. Nassir Marrouche’s Utah I–IV Classification System, see my article: Fibrosis Risk and the U. of Utah/CARMA website.

Reference for this Article
Image 1: Shivkumar K, Ellenbogen, Kenneth A, et al. Acute termination of human atrial fibrillation by identification and catheter ablation of localized rotors and sources: first multicenter experience of focal impulse and rotor modulation (firm) ablation. J Cardiovasc Electrophysiol. 2012 Dec; 23(12): 1277–1285. doi:  10.1111/jce.12000. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524347/

Image 2: Thomas, L. et al. Left Atrial Reverse Remodeling Mechanisms, Evaluation, and Clinical Significance. JACC: Cardiovascular Imaging. Volume 10, Issue 1, January 2017. DOI: 10.1016/j.jcmg.2016.11.003 http://www.imaging.onlinejacc.org/content/10/1/65

2017 AF Symposium: Preventing Esophageal Fistula

Report 14 from the 2017 AF Symposium summarizes a live ablation using a new tool to protect the esophagus.

The Problem: During an ablation, doctors take great precautions to not heat or injure the esophagus which lies behind the posterior wall of the left atrium. Injuring the esophagus can, in very rare cases, cause an atrial esophageal fistula which can be fatal.

Fear of causing esophageal injury can cause the EP to modify the ablation lesion set delivery, thereby reducing ablation success.

New Solution: an Esophagus displacement tool.

Use of the esophagus displacement tool, EsoSure Esophageal Retractor

The EsoSure Esophageal Retractor allows doctors to re-position a section of the esophagus away from the nearby heart tissue and avoid the heat generated during ablation.

Live streaming ablation: In this re-do ablation, entrainment (pacing) mapping was used to identify non-PV triggers.

Since they had to ablate in the posterior of the left atrium next to the esophagus, they simply moved the EsoSure Retractor up and down to displace the esophagus. The EPs remarked they could now ablate at a higher wattage without fear of harming the esophagus. …continuing reading my report…

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