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

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

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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: Findings from the CASTLE-AF Clinical Trial

by Steve S. Ryan, PhD.
FAQs Understanding Your A-Fib A-Fib.comPersonal note: Most people who’ve had a successful catheter ablation can tell you how wonderful it feels to have a heart that beats normally again. There are few other procedures that so improve one’s quality of life. (I had my procedure back in 1998 and still treasure being in normal sinus rhythm!)
One would think intuitively that having normal blood flow to the brain and body would improve overall health and lead to longer life. But there haven’t been many studies documenting this result…until now!
The findings of the CASTLE AF clinical trial are one of the most important studies for patients in the last decade!

Dr. Nassir Marrouche & the CASTLE-AF Clinical Trial

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

I reported briefly on the CASTLE AF clinical trial last October [see CASTLE AF Study: Live Longer―Have a Catheter Ablation]. At the time, it was a late-breaking study with few details.

Nassir Marrouche MD

N. Marrouche MD

At the January 2018 AF Symposium Dr. Nassir Marrouche presented results of the full CASTLE-AF study.

CASTLE-AF is a multicenter, randomized, controlled trial of A-Fib patients with managed heart failure. The trial was to determine if catheter ablation lowers morbidity and mortality as compared with drug therapy (rate or rhythm control).

The Case of the 50-Year-Old Man with an Ejection Fraction of 24%

Dr. Marrouche started his presentation by describing one of his patients, a 50-year-old man with A-Fib for 6 years who had progressed from paroxysmal to persistent. He’d taken various antiarrhythmic drugs (AADs) such as Sotalol and amiodarone.

Ejection Fraction is a measurement of the blood leaving your heart each time it contracts. Normal rate is 50%-75%.

He had failed Electrocardioversions. His Ejection Fraction (EF) was 24%―dangerously low and considered a stage of heart failure. [To learn more about EF, read my FAQ: Understanding A-Fib and Ejection Fraction.]

After a catheter ablation procedure, Dr. Marrouche’s patient’s Ejection Fraction improved from 24% to 44%. [This is a huge improvement! This man’s life was basically saved.]

Rate vs Rhythm Control & Amiodarone Toxicity

Dr. Marrouche discussed older studies such as AFFIRM comparing rate control drug therapy to rhythm control drug therapy using antiarrhythmic drugs (AADs).

Even though people on AADs were often in normal sinus rhythm and felt better, mortality in the rate control group and the AAD group was about the same. This somewhat surprising result may have occurred because one of the AADs used was amiodarone which is known for its toxic effects. [The toxicity of amiodarone may have offset the improved mortality of being in normal sinus rhythm.]

For more on amiodarone, see Amiodarone: Most Effective and Most Toxic)

Description of the CASTLE-AF Study

The 9-year, multicenter CASTLE-AF trial started in 2008 and focused on patients with A-Fib and systolic heart failure. The 398 participants were at 31 sites in 9 countries across Europe, Australia and the U.S.

Heart Failure occurs when it’s unable to pump enough blood to the other organs to satisfy their need for oxygen and nutrients (not that the heart has suddenly stopped).

All patients had sick hearts. Study participants had A-Fib, advanced heart failure (i.e., low ejection fraction less than 35%) and dual chamber Implantable Cardioverter Defibrillators (ICDs). Patients were randomized to receive either radiofrequency catheter ablation or conventional drug treatment.

Of the conventional drug therapy group, 30% were on antiarrhythmic drugs (AADs) and the rest were on rate control drugs.  (Note: amiodarone was used around 35% of the time as the AAD.)

EPs performing the RF catheter ablations could use whatever ablation techniques or systems deemed appropriate. 51% of ablation patients had additional isolation burns, mainly ablation lines and mapping/targeting complex fractionated atrial electrograms (CFAEs).

The median follow-up period was 37.8 months, which is longer than most other A-Fib ablation trials.

Results―Ablation Saves Lives―47% Reduction in Death Rate

Dr. Marrouche listed key results of the CASTLE-AF Clinical Trial:

Catheter ablation lowered the death rate by 47% vs conventional therapy;
In the catheter ablation group: 60% improved their ejection fraction by more than 35%;
After 5 years, 60% of the ablation group were in normal sinus rhythm compared to only 22% receiving conventional drug therapy;
There was a 51% reduction in cardiovascular mortality in the catheter group;
Even though 94% of the patients were taking Coumadin, the catheter ablation group’s stroke rate was ½ of the conventional drug treatment group;
There was a 38% reduction in all cause mortality and hospital admissions in the catheter group. A-Fib burden (percentage of time in A-Fib) also improved;
Heart failure hospital admissions improved immediately within 6 months of the ablation.

Dr. Marrouche stressed that catheter ablation for A-Fib patients should be performed early, the earlier the better. “…Ablate them early on, very soon in the disease stage.”

CASTLE-AF: Ablation Improves Quantity, Not Just Quality of Life

Catheter ablation was previously known to improve Quality of Life (QofL). But in the CASTLE-AF study, it also improved life outcomes (the quantity of life, how long one lives).

After catheter ablation, the death rate of trial patients was lowered by an amazing 47%! Catheter ablation improved lower-than-normal ejection fraction and consequently cured a major component of heart failure.

Presentation Q & A and Insightful Comments

Dr. Hugh Calkins, AF Symposium

Dr. Hugh Calkins

During the question and answer session after Dr. Marrouche’s presentation, Dr. Hugh Calkins of Johns Hopkins expressed the sentiments of not just the attendees but of all A-Fib patients and their doctors.

“This is such an unbelievably fantastic study. This is the first study to show that AF ablation improves mortality and heart failure. Hats off to you for getting this done. All of us believed in this procedure. But people kept asking us for hard end points (which you have provided).”
Dr. Douglas Packer

Dr. Douglas Packer

In a bit of hyperbole, Dr. Douglas Packer from the Mayo Clinic added,

“CABANA people everywhere were screaming with delight when they saw the results of your paper.”

Dr. Marrouche also talked about how difficult it was to get this study done, to get and keep funding, to motivate everyone involved to continue over the years. He especially thanked Medtronic Inc. for never wavering in their support of this study.

Editor’s Comments
My Anecdotal Evidence: I recently heard from a 73-year-old man I had advised who had persistent A-Fib. One month after an ablation by Dr. Andrea Natale, he is in normal sinus rhythm and his ejection fraction improved from a low 35% to a normal 55% (normal range is 50–75%)!
Even though he’s only a month into his blanking period, he reports he’s feeling terrific.
Today’s Ablation Treatments Strategies Much Improved: If the CASTLE-AF were started today rather than in 2008, we would expect to see even better results. There’s been a tremendous improvement in ablation treatment strategies over the years, such as contact force sensing catheters, balloon catheters, and advanced mapping systems.
Hard Data―Ablation Lowers Death Rate: Thanks to Dr. Marrouche and his colleagues, we now have hard data that a catheter ablation doesn’t just feel good but lets us live a healthier, longer life. It actually lowered the death rate of these very sick patients by 47% which is unheard of! (If the hard data weren’t there, no one would believe it.)
Dramatic Improvement in Heart Failure: People with congestive heart failure (low ejection fraction) say it sometimes feels like they are suffocating. (For those with advanced heart failure, nearly 90% die within one year.) Can you imagine what patients in the CASTLE-AF study experienced when their ejection fraction went from less than 35% to a 60% improvement? It’s like someone was giving them their life back again.

Personal note: When last measured, my EF was 65% ―pretty good for a 77-year-old.

Improvement of Ejection Fraction to 35% = No or Reduced Heart Failure: Over time A-Fib weakens the heart and reduces ejection fraction (leading to heart failure). Whereas patients in the ablation group reversed this remodeling effect. The most astounding statistic of CASTLE-AF is that 60% of patients improved their ejection fraction by 35% after their catheter ablation.
That kind of improvement means that many patients no longer suffered from heart failure. This is an amazing development in medicine. For people in this study, it’s like a miracle. They can now live more normal lives.
Less Hospital Admissions: A-Fib and heart failure are expensive diseases. A-Fib on average costs patients around $8,700/year. (See The Costs and Consequences of Living with Atrial Fibrillation . It’s not inconsequential that successful catheter ablations reduce hospitalizations and trips to the ER.
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.
The Bottom Line: Becoming A-Fib free by a catheter ablation doesn’t just make you feel better and gets rid of your A-Fib symptoms. We now have hard data that an ablation lets you live a healthier and longer life.

Addition reference: Marrouche NF, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378:417-427, Feb 01, 2018. http://www.nejm.org/doi/full/10.1056/NEJMoa1707855.

If you find any errors on this page, email us. Y Last updated: Thursday, April 19, 2018

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2018 AF Symposium: Kiss of Death for FIRM Mapping? The REAFFIRM Trial

In a late-breaking presentation, the interim results of the REAFFIRM trial were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center.

Focal impulse and rotor modulation (FIRM)

FIRM stands for Focal impulse and rotor modulation (FIRM) and is used for mapping electrical signals of the heart.

The trial was intended to assess the safety and effectiveness of FIRM mapping used with conventional ablation (including PVI) versus a standard PVI procedure for the treatment of persistent atrial fibrillation.

REAFFIRM Trial Design

In a prospective multi-center trial, 350 patients with persistent or long-standing persistent A-Fib who had not had a previous ablation were randomized in a 1:1 fashion. The trial was designed to compare FIRM mapping used with standard catheter ablation (including PVI) versus PVI without use of FIRM mapping.

The non-FIRM ablation control group included…Continue reading this report->

Review All My Reports

To browse all my 2018 reports, go to my 2018 AF Symposium page (or use the link in the left menu column).

My 2018 reports

2018 AF Symposium My Last 2 Live Procedures Reports

The Left Atrial Appendage was a popular topic at the 2018 AF Symposium. My last live case reports present two more ways for isolating the Left Atrial Appendage, one an occlusion device and the other using a CryoBalloon catheter.

Amplatzer Anulet

Installing an Amplatzer™ Amulet™ LAA Occluder

Dr. Claudio Tondo from Milan, Italy, demonstrated an LAA closure by inserting the Amplatzer Amulet LAA closure device. Because of the patient’s history of major bleeding, Dr. Tondo decided to close off her LAA first while postponing a PVI until later. (In Europe, a LAA occluder can be inserted at the same time as a catheter ablation). (See also, Installing a Coherex WaveCrest LAA Occlusion Device.)

The Amplatzer has two lips which close over both the outside and the inside of the LAA―like a sandwich…Continue reading this report->

CryoBalloon catheter

CryoBalloon catheter

CryoBalloon Catheter for Isolation of the LAA

To isolate the Non-PV triggers originating in the patient’s Left Atrial Appendage, Dr. Knight used a CryoBalloon catheter in order to penetrate deeper into the LAA tissue.

Using the CryoBalloon Catheter for this procedure is an “off-label use”, i.e., a new use not described in the FDA approved device labeling. (Also see, Isolating the Left Atrial Appendage using RF Energy) Dr. Knight used a 28mm CryoBalloon catheter… Continue reading this report>

Read My Other Live Case Reports

To browse all my 2018 reports, go to my 2018 AF Symposium page (or use the link in the left menu column).

My 2018 reports: more to come

2018 AF Symposium Live Case: CryoBalloon Catheter for Isolation of the LAA

by Steve S. Ryan, PhD.

B. Knight MD

During this live streaming video, Dr. Bradley Knight from Northwestern Un. in Chicago, IL demonstrated the use of a CryoBalloon Catheter to isolate the Left Atrial Appendage (an off-label use, i.e., a new use not described in the FDA approved device labeling.).

Patient background: His patient was a 72-year-old man with hypertension and persistent A-Fib. He had an ablation in 2013. His ejection fraction was low but improved after a cardioversion to 40%. July 15, 2017 he had a right atrium Flutter ablation. He was on amiodarone which had to be stopped because of thyroid problems.
He developed severe Left Atrium enlargement and his ejection fraction went down to 30%. His PVs was were very large and hard to isolate. It was recommended to do both a repeat PVI and to isolate the LAA.
Live Streaming Video from AF Symposium at A-Fib.com

Isolating the Left Atrial Appendage

To isolate the Non-PV triggers originating in the patient’s Left Atrial Appendage, Dr. Knight used a 28mm CryoBalloon catheter in order to penetrate deeper into the LAA.

A second freeze was performed and then a third freeze was necessary because the LAA was still generating A-Fib signals. Before we could see this third freeze, the allotted time slot ran out.

The use of the CryoBalloon catheter appeared to be an effective treatment (though an off-label use) to isolate the LAA.

Editor’s comments:
I was surprised that two CryoBalloon lesions didn’t effectively isolate the patient’s LAA and a third lesion was necessary.
On the other hand, the use of the CryoBalloon catheter to isolate the LAA is in the very preliminary stage of research.
From watching Dr.Knight’s live case, it doesn’t seem like the CryoBalloon catheter will emerge as a viable method of electrically isolating the LAA.

If you find any errors on this page, email us. Y Last updated: Thursday, March 1, 2018

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2018 AF Symposium: REAFFIRM Trial—Kiss of Death for FIRM Mapping?

by Steve S. Ryan, PhD

John Hummel MD

In a late-breaking presentation, the interim results of REAFFIRM were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center.

Focal impulse and rotor modulation (FIRM)

Note: REAFFIRM stands for “Randomized Evaluation of Atrial Fibrillation Treatment with Focal Impulse and Rotor Modulation Guided Procedures” (REAFFIRM).
FIRM stands for Focal impulse and rotor modulation (FIRM) and is used for mapping electrical signals of the heart.

The trial was intended to assess the safety and effectiveness of FIRM mapping used with conventional ablation (including PVI) versus a standard PVI procedure for the treatment of persistent atrial fibrillation.

REAFFIRM Trial Design

In a prospective multi-center trial, 350 patients with persistent or long-standing persistent A-Fib who had not had a previous ablation were randomized in a 1:1 fashion. The trial was designed to compare FIRM mapping used with standard catheter ablation (including PVI) versus PVI without use of FIRM mapping.

The non-FIRM ablation control group included CTI (Cavo Tricuspid Isthmus Ablation for atrial flutter) and extra non-PV trigger ablations. Irrigated catheters were used in all cases, but not all used contact force sensing catheters.

Patients were monitored for 12 months with Holter and implantable monitors. The patients were primarily white males 65+ years old. There were no significant differences in the two groups of patients.

Trial Results: No Significant Difference in FIRM+PVI vs. PVI Alone

Prediction: It was anticipated that the control arm (PVI alone) would have a freedom from A-Fib success rate of 40% versus the treatment arm (FIRM+ PVI) would have a success rate of 75%.

Actual: At 12 months the success rate of the treatment (FIRM+ PVI) was 78%, while the control group with PVI alone had a success rate of 70%. This was a non-significant difference (not what the researchers had expected).

Translation: The control arm of the trial (PVI alone) did much better than anticipated. The researchers are trying now to look more closely at the details of the non-FIRM trial to identify why it did so well.

What this Trial Means for Patients

The REAFFIRM trial was a well designed study which showed that FIRM is not significantly better that a standard well-performed PVI ablation.
This is not the first study to call into question the effectiveness of the FIRM system. Critical Analysis of the FIRM Mapping System (2015) and More FIRM Research: Mapping System Falls Short (Again) (2016).
Unless and until the smoke clears and we have further research, the FIRM system probably won’t be an effective player long-term in the world of A-Fib ablation.
Bottom line: Don’t go out of your way to find a center or EP using the FIRM mapping system.

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

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2018 AF Symposium Live Case: Installing a Coherex WaveCrest LAA Occlusion Device

by Steve S. Ryan, PhD.
Background: The Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device is not yet approved by the FDA for use in the U.S. The WaveCrest is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved).

Tom De Potter MD

Dr. Tom De Potter of Aalst, Belgium, presented a live case in which he installed a Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device in an 84-year-old female with longstanding A-Fib and a bleeding problem.

The WaveCrest has roll-out anchors which are then fixed into the sides of the LAA. It comes in three sizes to fit different LAA openings.Live Streaming Video from AF Symposium at A-Fib.com

He spent a good deal of time and attention washing and immersing the WaveCrest in water to make sure there were no bubbles.

When the device is expanded inside the LAA, it can be repositioned and recaptured. Dr. Potter seemed to tug and firmly push and pull the device to anchor it.  After insertion, it requires 2 months of dual antiplatelet therapy.

WaveCrest is from Coherex Medical, Inc., a subsidiary of Biosense Webster/Johnson & Johnson.

Coherex WaveCrest Video

Video still frames of Coherex WaveCrest occlusion device positioned in LAA.

Video animation is available: The Coherex Medical website has a short (35-second) showing the installation of the Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device. Go to video on the Coherex website->

Editor’s Comments:
To me the WaveCrest seemed similar to Boston Scientific Watchman LAA Closure Device which did all the heavy lifting to be the first LAA occlusion device to get U.S. FDA approval.
I didn’t see major significant advantages of the WaveCrest. Though it’s always good for EPs to have a choice of devices when closing off the LAA.
For more on the Watchman, see  my article, The Watchman™ Device: An Alternative to Blood Thinners. 

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

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2018 AF Symposium Live Case: Installing an Amplatzer™ Amulet™ LAA Occluder

by Steve S. Ryan, PhD.

Illustration: Amplatzer Amulet in LAA

On the Thursday session on Left Atrial Appendage Closure, two live cases were presented via streaming video from around the world.

Here, I cover the first live case featuring the Amplatzer™ Amulet™ Left Atrial Appendage (LAA) occlusion device. (For my report on the other occluder, see: Installing a Coherex WaveCrest LAA Occlusion Device.)

Note: The Amplatzer™ Amulet™ Left Atrial Appendage (LAA) Occluder, is not yet approved by the FDA for use in the U.S. It is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved). The Amplatzer™ Amulet™ is from Abbott (formerly St. Jude Medical).

Patient Background: An 81-year-old lady with acute hypertension was in permanent A-Fib since 2016. Her CHADS2VASc score was 5 (at the top of the risk range), her HAS-BLED score was 4 (high for one year risk of major bleeding). She had suffered syncope (fainting) episodes and had a history of major bleeding on anticoagulants (the reason for the LAA closure). On the positive side, her Ejection Fraction was a healthy 61%.

Live From Milan, Italy

Claudio Tondo, MD

Dr. Claudio Tondo from Milan, Italy, demonstrated an LAA Closure by inserting an Amplatzer LAA closure device.

In Europe, a LAA occluder can be inserted at the same time as a PVI (catheter ablation). But for the AF Symposium live session, only the Amplatzer Amulet™ was inserted.  (Because of her history of major bleeding, Dr. Tondo decided to close off her LAA first while postponing a PVI till later.)

Amplatzer Amulet Features

Amplatzer™ Amulet™ illustration at A-Fib.com

Amplatzer™ Amulet™

The Amplatzer has two lips which close over both the outside and the inside of the LAA―like a sandwich. It comes in different sizes to fit better into different sized LAAs.

One advantage of the Amplatzer is less risk of leaking because the inside and outside lips overlap the opening of the LAA. Over time, heart tissue grows over the implant, becoming part of the heart.

Inserting the Amplatzer LAA Occluder

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

The primary imaging technology used to insert the Amplatzer was Intracardiac Echo, though fluoroscopy was used as an adjunct to help the audience follow the procedure. In the Echo you could see the Amplatzer being positioned and inserted into the LAA. (I could follow the fluoroscopy but found it hard to follow the Echo.)

Dr. Tondo described her LAA shape as “chicken wing” which is usually an LAA shape easier to close off. It appeared relatively easy to insert the device into the patient’s LAA, then fit it snugly into the LAA opening.

Dr. Tondo and his team used a type of dye pumped in behind the Amplatzer to see if there was any blow back or leaking. Once that was done, they simply disconnected the catheter used to insert the Amplatzer.

Amplatzer™ Amulet™ Video

A short animation from Abbott (formerly St. Jude Medical) illustrates insertion of the Amplatzer™ Amulet™ LAA Occluder (1:14). To watch the video, go to Abbott webpage->

Editor’s Comments:
About this patient: This 81-year-old lady was in a very difficult, risky situation. Her stroke risk was very high, but she couldn’t take anticoagulants to prevent a stroke because they caused her bleeding. By inserting the Amplatzer Amulet device to close off her Left Atrial Appendage (LAA), Dr. Tondo would significantly lower her risk of an A-Fib stroke which mostly comes from the LAA.
Her persistent A-Fib was very symptomatic with dangerous fainting episodes. She needed a catheter ablation to get her back into normal sinus rhythm. Dr. Tondo planned to perform the PVI as soon as possible after her LAA closure.

Two LAA occluder devices

About the Amplatzer Amulet: Having previously watched the Watchman Device procedure, to me the Amplatzer Amulet seemed simpler to insert. Though both are realitivly easy to install.
One potential problem with an Amulet might occur if a subsequent catheter ablation requires the LAA to be mapped and isolated. It will be harder to do so because the lips of the Amulet cover the LAA opening.
In Europe, the Amplatzer Amulet is used to close holes in the septum (called ‘patent foramen ovale’, i.e., a hole in the heart that didn’t close the way it should after birth.).
Once approved in the U.S. by the FDA, it will probably become a competitor or an alternative to the Watchman Device.

If you find any errors on this page, email us. Y Last updated: Wednesday, March 7, 2018

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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

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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

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