ABOUT 'BEAT YOUR A-FIB'...


"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

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"



ABOUT A-FIB.COM...


"Steve Ryan's summaries of the Boston 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

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


AF Symposium & other Medical Conferences

My First 3 Reports from MAM 2016

I’ve written and posted three short reports from the recent HEART TEAM: 2016 Multidisciplinary Arrhythmia Meeting (MAM) held in Zurich, Switzerland:

♥ MAM 2016: Moving A-Fib Care to a New Level (Overview)
This is an overview of the first MAM symposium which advocates for a team approach, a Hybrid Surgery/Ablation, in which EPs and surgeons work together on difficult A-Fib cases. 

 Transcript: My Challenge to Doctors Treating A-Fib Patients – My MAM Speech
As the only patient invited to speak, you may want to read the speech I gave to over 200 EPs and surgeons sharing the patient’s point-of-view.

 Fantastic Experience of the Heart, or Why we were wearing 3-D glasses! A presentation by Dr. Joris Ector, from the University of Leuven, Belgium.

The Hybrid Surgery/Ablation is becoming an increasingly important and effective strategy for highly symptomatic patients with persistent atrial fibrillation or longstanding persistent atrial fibrillation who have failed one or two catheter ablations, and for the patient with a significantly enlarged left atrium.

Learn more about Hybrid Surgery/Ablation on our Cox-Maze & Mini-Maze Surgeries Treatments page.

MAM 2016: Fantastic 3-D Experience of the Heart or Why We Were Wearing 3-D glasses!

fantastic-voyage-ship-in-vein-400-x-300-pix-at-300-res

The movie won an Oscar for Best Special Visual Effects; Image: Foresight Institute

by Steve S. Ryan, PhD

In 1966, the wide-screen movie Fantastic Voyage took viewers inside the human body by injecting a miniaturized submarine, its crew and a surgical team into the carotid artery. Their mission was to break up a clot and save the VIP patient. Traveling through the heart to the brain, reveals a world of dazzling color, a floating wonderland with huge red corpuscles, whirling globules, platelets and particles.

I had that same amazing experience when Dr. Joris Ector presented his incredible 3-D vision of a real heart. Just like when watching the movie, there were involuntary gasps and shocks as you felt what it was like to move through the heart.

And yes, we had to wear 3-D glasses! That’s got to be a first at an A-Fib conference.

Joris Ector MD, with 3D glasses at MAM 2016 - A-Fib.com

Joris Ector MD, wearing 3D glasses; Inset: the exterior of the 3-D heart

Starting with the exterior of a beating heart, Dr. Ector, from the University of Leuven, Belgium, showed every possible 3-D angle.

Next, he peeled away the exterior to reveal the movement of the heart from the inside. Next, he whisked you inside the heart so fast that you almost got dizzy.

Particularly interesting was the trip through the left atrium into the Left Atrial Appendage (LAA) with its trabeculations (thick muscular tissue bands) which looked like columns in close-up.

In some ways, Dr. Ector’s presentation felt more real and comprehensive than watching footage of an actual heart beating. It was an astounding experience (just like watching Fantastic Voyage in 1966). (I wish I had an interior of the 3-D heart to share with you.)

Image credit: Fantastic Voyage movie still from Foresight Institute

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If you find any errors on this page, email us. Last updated: Friday, October 7, 2016

 

MAM 2016: My Challenge to Doctors of A-Fib Patients

Steve Ryan at the entrance to the MAM 2016 symposium - A-Fib.com

Steve at the entrance to the MAM 2016 symposium

In September, I was the only patient invited to present at MAM 2016 in Zurich, Switzerland. After dinner the first night, I spoke to over 200+ surgeons and electrophysiologists (EPs).

I tried to describe for the doctors what it’s like to live in Atrial Fibrillation. Here is what I told them.

You Never Forget Your First A- Fib Attack

“As most A-Fib patients will testify, you never forget your first A- Fib attack.
Mine was 19 years ago, but I can remember it like it was yesterday. All of a sudden my heart started going crazy! It felt like my heart was trying to jump out of my chest or like there was a live fish flopping around in there. I can still feel the sheer terror, fear, confusion, anxiety and worry it created.
I remember thinking, “Am I going to die?” “Is this a heart attack?” It was one of the most terrifying experiences of my life.
Most symptomatic A-Fib patients have a similar story.

Psychological and Emotional Effects of A-Fib

A-Fib doesn’t just affect you physically, it affects you emotionally as well.
A-Fib affects not just your heart—but also your head—and your quality of life.
It affects not just your heart—but also your head—and your quality of life.
By the way, I’ve never been to a medical conference where this aspect of A-Fib was studied.  (Today is a first, I guess.)
I wish there were some way to give you a one-minute episode of A-Fib. It would change your perception of A-Fib forever. The psychological and emotional aspects of A-Fib can be as bad as or even worse than the physical.

Living in Fear (and Anger)—A-Fib Wrecked My Life

In my case, I lived in fear of the next A-Fib attack. I went through all the emotional gamut—anxiety, fear, worry, confusion, uncertainty, frustration, depression, and finally anger at my own heart.
I went through all the emotional gamut—anxiety, fear, worry, confusion, uncertainty, frustration, depression, and finally anger at my own heart.
I’m a passionate runner. I used to run along Venice Beach. But my heart would go crazy and beat too fast. I’d have to stop and walk back to our apartment. Talk about frustration!
And A-Fib affected my work. I had a great job on the soap opera “Days Of Our Lives” as part of the technical crew. But I’d get dizzy and light headed and nearly lost my job. A-Fib wrecked my life!

Research—Then Going to Bordeaux for an Ablation

Steve Ryan before PVI, in Bordeaux, France, April 1998 at A-Fib.com

Steve Ryan before PVI, in Bordeaux, France, April 1998

To make a long story short, I locked myself in a medical library and read everything I could find about Atrial Fibrillation. During this time, I tried every drug known to man including the dreaded amiodarone which made me cough up blood. Nothing worked.
I found that doctors in Bordeaux, France, had discovered how to make people A-Fib free.
One of the doctors who treated me with catheter ablation is here today, Dr. Dipen Shah. Thanks to him, Dr. Haissaguerre and Dr. Jais I’ve been A-Fib free for 18 years. I was their first US patient.

My Challenge to Doctors treating A-Fib Patients

Today I want to challenge you. Just ask yourself:

What are you doing to help your patients deal with the Fear and Anxiety of A-Fib?

What are you doing to help them cope with the Psychological and Emotional effects of A-Fib?

Helping Your Patients Deal With Stress and Anxiety

Knowledge is Power and Control! Learning about A-Fib relieves worry and anxiety. Two ways to help your patients:
1. Reference books and websites. Give your patients a short list of web sites and books which you have read and recommend. If you do this, think of how much better informed your patients will be! 
Knowledge is Power and Control! Learning about A-Fib relieves worry and anxiety.
Hint: For distribution, list your recommendations on the back of a business card. If it comes from you, your patients will devour them.
2. Counseling and medication. You should have a list you can give out of several psychiatrists who understand A-Fib and how it affects patients.
You’ll know who needs this kind of help. Men, especially, may not admit to themselves that they need help.

Thanks for Making Us A-Fib Free

Steve S. Ryan - high jump at track meet

Steve, age 75; Making a high jump at track meet

Finally, I want to thank you on behalf of all the patients you’ve made A-Fib free. There are few medical procedures as transformative and life changing as going from A-Fib to Normal Sinus Rhythm.
There is simply no comparison between living in A-Fib and being A-Fib free! Normal Sinus Rhythm is wonderful!
There’s nothing like having a heart that beats normally again. No more tiredness, dizziness. being light headed. Your body feels alive. Your brain works. You can run and exercise again. [See the photo at right of me doing the high jump at age 75!]
Thank you for giving me my life back!”

After my talk I received enthusiastic complements and ‘fist bumps’.

I think I really made an impression. I don’t think anyone had ever talked to these doctors like that before.

My hope is that the effects of my talk will trickle down to helping others with Atrial Fibrillation.


Return to Reports of A-Fib Medical Symposiums & Conferences

If you find any errors on this page, email us. Last updated: Thursday, October 6, 2016

 

 

Heart Team/MAM 2016: Moving A-Fib Care to a New Level

Multidisciplinary Arrhythmia Meeting 2016Totally historic! The MAM 2016 symposium set important goals for shaping the future of A-Fib care and showed how the emphasis on a ‘Heart Team’ is moving the field of patient A-Fib care to a new level.

This first Multidisciplinary Arrhythmia Meeting (MAM) was held in Zurich, Switzerland Sept 15-16, 2016 and advocated for a team approach―EPs, Surgeons, and other healthcare professionals working together to better help the A-Fib patient.

Leading cardiologists and surgeons explained why they favored the hybrid surgery/ablation referred to by several terms: “hybrid simultaneous,” or “hybrid staged,” or “multidisciplinary sequential approaches”.

MAM 2016 Hands-on demos at A-Fib.com

MAM 2016 Hands-on demos

Interactive Hands-On Workshops and Live Surgery

MAM 2016 featured interactive workshops with hands-on experiences in EP ablation, Surgical Ablation, and Mechanical Exclusion of the Left Atrial Appendage (LAA). Included were working examples of clinicians, electrophysiologists and surgeons teaming up to better help A-Fib patients.

MAM 2016 Live video feed of A-Fib surgery at A-Fib.com

Live video feed of A-Fib surgery by Dr. Stefano Benussi and staff

Observing via a live video feed, attendees watched Dr. Stefano Benussi and his colleagues perform a surgery of an A-Fib patient showing both the left side and right side approaches. (The patient had a huge amount of fat which first had to be cut away before the pericardium sac could be reached and cut into in order to access the heart and pulmonary veins.)

MAM 2016 Program and Faculty

Dr. Stefano Benussi and Steve Ryan in Zurich at A-Fib.com

Dr. Stefano Benussi and Steve Ryan, PhD

The  Multidisciplinary Arrhythmia Meeting was the brain child of the Course Director Dr. Stefano Benussi of the University Hospital Zurich, Switzerland. Course Co-Directors were Harry Crijins of Maastricht, the Netherlands and Firat Duru of Zurich, Switzerland.

The Program Committee and Scientific Faculty making presentations included 54 distinguished doctors from around the world including the famed inventor of the original Cox Maze operation, James L. Cox of Denver, USA. (The Cox Maze operation was the first treatment to make patients A-Fib free.)

A partial list of MAM 2016 participating doctors and countries:

Steve in front of MAM 2016 meeting site in Zurich - A-Fib.com

Steve in front of MAM 2016 meeting site in Zurich

Manuel Castella, Barcelona, Spain
Paolo Della Bella, Alberto Pozzoli, Claudio Tondo, Milan, Italy
Karl Heinz Kuck, Andreas Metzner, Hamburg, Germany
Bart van Putte, Utrecht, The Netherlands
Malcolm Dalrymple-Hay, Guy Haywood, Plymouth, UK
Joris Ector, Mark La Meir, Laurent Pison, Brussels, Belgium
Hans Kottkamp, Diana Reser and many more from Zurich, Switzerland
Gunther Laufer, Vienna, Austria
Randal Lee, Bing Liem, Steve S. Ryan, California, USA
Ju Mei, Shanghai, China
Peter Mueller, Dipen Shah, Geneva, Switzerland
Amiran Revishvili, Moscow, Russia
Timo Weimar, Stuttgart, Germany
Michael Zembata, Zabrze, Poland

Additional presenting doctors will be identified along with summaries of their individual presentations.

My presentation summaries will follow.

Return to Reports of A-Fib Medical Symposiums & Conferences

If you find any errors on this page, email us. Last updated: Monday, October 3, 2016

 

Report 2: Highlights from the 2016 Western AF Symposium

Second in a series by Steve S. Ryan

These are highlights from my second report covering six presentations from the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Read my First Report with 9 brief summaries.

Contact Force sensing catheters. From the perspective of an A-Fib patient, the most exciting news was about developments to improve Contact Force sensing catheters. (They are already a huge improvement in RF catheter ablation). In addition to providing theelectrophysiologist (EP) with force and contact info, the new catheters will integrate duration, power, catheter stability and temperature to improve ablation quality.

Snow and skiing in Park City, UT

Park City, UT, site of the 2016 Western AF Symposium

The Laser Fiber Optic Balloon catheter seems also to have great potential. But we just don’t know if it will ever be approved for use in the U.S.

Successful A-Fib ablation=little stroke risk. Dr. Callans’s data showed that patients with a successful A-Fib ablation had very little stroke risk. Whereas, of those still taking anticoagulants after a successful ablation, 2% had an hemorrhagic stroke. Putting patients on anticoagulants after a successful catheter ablation is both ineffective and dangerous.

Continuous monitoring for A-Fib in all over 65? Dr. Mittal (and many at the Western Symposium presenters), expressed the increasing awareness that people over 65 need better monitoring than just an annual office ECG. The goal should be for everyone over 65 to have a practical form of continuous monitoring to detect A-Fib before it becomes a problem (i.e., causes a stroke). This is a major public health issue.

NOACs and Catheter Ablation. If you are on the NOACs Xarelto and Eliquis, Dr. Natale’s data is encouraging news. When having a catheter ablation, you don’t have to switch back to warfarin beforehand.

No Strokes among 2,618 ablations. Also very encouraging, was Dr. Natale’s data that there were no strokes among the 2,618 ablations performed by his groups. This is especially impressive because among their patients, there was a higher prevalence of nonparoxysmal A-Fib and higher CHADS2 scores. (Translation: Their patients had more severe cases of A-Fib and more risk factors for stoke.)

These are just the highlights. To read my entire second report, go to Report 2: 2016 Western Atrial Fibrillation Symposium.

Look for my third report in the series in the coming weeks.

Report 1: Brief Summaries from the 2016 Western AF Symposium

Utah! What a wonderful winter venue for the Ninth Annual Western Atrial Fibrillation Symposium held  February 26-27, 2016.

Skiing in Park City, UT

Park City, UT

After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant information was provided (sometimes by the same presenters). In all, there were 53 scheduled presentations of 15 minutes each.

My first report includes 9 brief summaries of technical presentations.

Ablation vs Drugs: From AFFIRM to Recent Guidelines

Dr. Eric Prystowsky discussed the now somewhat notorious AFFIRM study which many cardiologist still use to justify keeping A-Fib patients on rate control drugs (and anticoagulants) while leaving them in A-Fib.

But the AFFIRM study was only for 3-5 years. Leaving someone in A-Fib for 20-30-40 years while only trying to keep their heart from beating too fast can have disastrous long-term consequences for A-Fib patients.

To continue reading, go to Report 1: 2016 Western AF Symposium.

Steve Reporting from Western AF Symposium in Utah

Leading cardiologists and researchers are gathering this Friday and Saturday for The Ninth Annual Western Atrial Fibrillation Symposium in Park City, UT., co-sponsored by the Heart Rhythm Society.

Steve was invited to attend by the symposium organizer, Dr. Mousa Mansour, University of Utah, Salt Lake City, UT. (See Steve’s report of Dr. Mansour’s presentation from the 2016 AF Symposium, Orlando, FL.) I’m sure Steve’s WAFS reports will complement his growing list of reports from the recent 2016 AF Symposium.

Steve S. Ryan - high jump at track meet

Steve – high jump at Feb. 14 track meet

High Altitude and the High Jump

Steve loves to jog and compete in his age group in various track and field events (last weekend it was the high jump, long jump and 100 meter dash).

I was thinking about Park City, Utah, being at 6,000 feet above sea level. You see, we live at sea level in Malibu, CA.

So, I was wondering if Steve’s recent ‘high jump’ events might help him deal with the high altitude and thinner air? (Hee, hee.) What do you think?  (LOL)

Photo is by fellow week-end athlete, Ken Stone.

2016 AF: Four New Reports on Predictors, Protocols, Rotors & 2 Difficult Ablation/LAA Cases

New Reports by Drs. Haissaguerre, Wilber, Reddy & Valderrabano

I’ve been rather prolific with my summaries of key presentations from the recent 2016 AF Symposium (January, Orlando, FL). Four new reports have been posted at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

Dr Michele Haissaguerre, The Bordeaux Group

Dr Michele Haissaguerre

You might want to start with two presentations by the A-Fib research pioneer1Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France (he cured my A-Fib in 1998):

Predictors of Unsuccessful Ablations: It’s All About Remodeling
• Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation

Then move on to the very HOT topic of Rotors, and two difficult cases of ablation with LAA closure:

• Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib. presented by Dr. David Wilber of Loyola University Medical Center, Chicago, IL
• Two Challenging, Difficult Catheter Ablation Cases with LAA Closure by Dr. Vivek Reddy, Mount Sinai Hospital, New York, NY and Dr. Migel Valderrabano, Houston Methodist Hospital, Houston, TX

More Reports to Come

Steve at 21st Annual AF Symposium in Orlando FL

Steve at 2016 AF Symposium

 You can see a list of my first six reports at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

For an introduction to the 2016 AF Symposium, don’t miss my brief Overview.

I expect to write 15 – 20 additional reports in the coming months. So visit the reports list often. Just use the left menu tab “2016 AF Symposium Reports” (found on every page) to go to my growing list of reports.

Citation for this article
References    (↵ returns to text)

  1. Pioneer in the Ablation of A-Fib: In 1997, a major breakthrough came to AF ablation as Dr. Michel Haïssaguerre and his researchers observed that a vast majority of A-Fib was initiated by triggers from a focal source in the Pulmonary Veins (PV) and ablation of the focal source in the PV eliminated Parosysmal A-Fib.

2016 AF: Thickening of Left Atrium and Fibrosis Amount Predicts Outcome of A-Fib Ablation

AF Symposium 2016

Thickening of Left Atrium and Amount of Fibrosis Predicts Outcome of A-Fib Ablation

by Steve S. Ryan, PhD

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche, University of Utah (CARMA), is known for ground-breaking, thought-provoking research using MRI. His presentation was entitled “Atrial and Ventricular Myopathy: A Novel risk predictor for stroke and cardiovascular events.”

Amount of Fibrosis Better Predictor of Stroke Risk (and Heart Attack)

Dr. Marrouche began by showing how today’s stroke guidelines (CHADS2 or CHA2DS2-VASc) are mediocre predictive tools overall, according to most studies. Whereas atrial fibrosis detected by Delayed Enhancement-MRI (DE-MRI) is a better predictor of stroke risk.

DE-MRI stands for Delayed Enhancement Magnetic Resonant Imaging.

In Dr. Marrouche’s study, patients with more than 21% fibrosis had a 19.6% risk of stroke while those with under 8.5% fibrosis had only a 1% risk. The more fibrosis, the greater risk of clots forming in the Left Atrial Appendage (LAA).

In a study by King, higher levels of fibrosis were associated with ‘Major Adverse Cardiac Events’ (MACE), not only stroke but heart attack and deep vein thrombosis (a blood clot within a vein).

Cardiomyopathy and Fibrosis

Dr. Marrouche showed slides of normal atrial myocytes (muscle cells) vs. examples with extensive fibrosis where collagen replaced most of the red myocytes (which store oxygen until needed for muscular activity).

This is an important finding which may change the way we look at fibrosis.

This fibrosis correlated with abnormality of the atria (atrial myopathy) and deterioration of the ability of heart muscles to contract (cardiomyopathy). This is an important finding which may change the way we look at fibrosis.

(For further information on Dr. Marrouche’s work, see Higher Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation.)

Fibrosis/Myopathy Correlates with Atrial Strain

Dr. Marrouche showed slides of how the left atrium of an A-Fib patient with extensive fibrosis worked much harder to pump and had nearly three times more strain than a patient with mild fibrosis. (This may be why the left atrium often stretches and expands in remodeling.)

A-Fib Thickens Left Atrial Shape

In another ground-breaking observation, Dr. Marrouche showed slides of how the shape of the left atrium (LA) gets thicker as one progresses from no-A-Fib to paroxysmal to persistent A-Fib. In fact, in a study by Bieging, LA shape (thickness) is a strong independent predictor of outcome after AF ablation.

Left Atrial Appendage and Stroke Risk

Dr. Marrouche found that the Left Atrial Appendage (LAA) length, thickness and orientation correlate with stroke risk. These findings open up new avenues of research in A-Fib. Just looking at the LAA might produce an indication of stroke risk, which can be combined with other predictive measures.

Left Ventricular Disease Predicts Recurrence after Ablation Therapy

Some A-Fib patients also have a diseased Left Ventricle (LV) which shows up using ‘Late Gadolinium Enhancement- MRI’ (LGE-MRI). In a study by Suksaranjit, the recurrence rate after an ablation was 69% in patients with Left Ventricular LGE-MRI revealed disease, compared to 38% in patients without LV LGE-MRI. These patients also have more major adverse cardiac and cerebrovascular events.

Conclusion

Dr. Marrouche is now using both the amount of fibrosis and left atrial shape to stage and treat A-Fib patients. The main points we can learn from Dr. Marrouche’s research are:

Fibrosis makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems.

• Fibrosis puts you are greater risk of a stroke and other vascular problems.
• More fibrosis leads to thickened heart tissue, strains the heart and reduces the ability of the heart muscles to contract.
• A-Fib changes the thickness/shape of the left atrium.
• A-Fib can also change the length, thickness and orientation of the Left Atrial Appendage (LAA).
• Left Ventricular disease may accompany or be caused by A-Fib, be measured by MRI, and predict recurrence after catheter ablation..

What Patients Need To Know

Don’t delay! Your A-Fib leads to fibrosis! A-Fib produces fibrosis which is considered permanent and irreversible. Any treatment plan for A-Fib must try to prevent or stop remodeling and fibrosis.

Caveat: After reading Dr. Marrouche’s research and new insights that atrial fibrosis detected by DE-MRI is a better predictor of stroke risk (than CHADS2 or CHA2DS2-VASc), don’t rush into your EPs office asking about using MRI to diagnose your amount of fibrosis. Not every MRI technician and doctor has the special training and experience necessary to perform Dr. Marrouche’s testing. (And insurance companies may not want to pay for this testing. However, that may soon change.)

References for this article

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2016

More FIRM Research: Mapping System Falls Short (Again)

Background: FIRM stands for ‘Focal Impulse and Rotor Modulation’; The FIRM mapping and ablation system uses a basket catheter, a panoramic contact-mapping tool by Topera/Abbott Laboratories. Rotors (rotational circuits or focal sources) are underlying drivers that sustain or perpetuate an A-Fib signal after it has been triggered (like an echo).
The FIRMap basket Catheter from Topera/Abbott Laboratories

The FIRMap basket catheter

A three-center 2015 study (Gianni) used FIRM-guided only ablation on 29 patients with persistent or long-standing persistent A-Fib. The centers were:

• The Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
• The Heart Center Bad Neustadt, Bad Neustadt, Germany
• Baptist Health, Lexington, KY, USA

Undergoing FIRM mapping, 20 patients had persistent A-Fib and 9 patients had long-standing persistent. Doctors found 4 rotors (on average) per patient (with 62% coming from the left atrium) and 1 focal impulse. All these signal sources were successfully ablated.

Follow-up Ablation Results

After a mean of 5.7 months of follow-up, single procedure freedom from A-Fib/Flutter without antiarrhythmic drugs was a low 17%.

Researchers concluded that the FIRM system was not effective in returning patients to normal sinus rhythm (or alternatively moving from the chaotic A-Fib rhythm to a more regular rhythm such as A-Flutter). And only ablating FIRM-identified rotors did not prevent recurrence (i.e., return of A-Fib).

Other Research on the FIRM System

AF Symposium logo

AF Symposium reports

This study confirms the January 2015 AF Symposium presentation, Critical Analysis of the FIRM Mapping System, by Dr. Ravi Mandapati of Loma Linda University,

From a different perspective, Dr. Vivek Reddy offers a real world application of the FIRM system (advantages and problems). See the 2016 AF Symposium presentation: Two Challenging, Difficult Catheter Ablation Cases.

Bottom line for Patients

Even though the FIRM mapping and ablation system seems to currently have built-in limitations, master EPs still use the FIRM basket mapping catheter because it provides a great deal of important information very quickly. It is especially useful in cases of Persistent A-Fib.

Note: The developer of FIRM, Topera/Abbott Laboratories, is working to address shortcomings by developing its own line of mapping basket catheters.
References for this article

2016 AF Report: Hot Topic—Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib

AF Symposium 2016

Hot Topic: Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib

by Steve S. Ryan, PhD

Rotors have become increasingly important in treating and ablating Atrial Fibrillation, particularly for Persistent A-Fib.

Rotors was such a hot topic, one could have called this year’s symposium the “2016 Rotor Symposium”.

If you have Persistent (or Long-standing A-Fib), you’ll want to seek out and be treated by EPs who understand rotors and recognize their importance.

Can Fibrotic Heart Tissue be Ablated?

Many EPs don’t ablate A-Fib patients with a high level of fibrosis and consider fibrotic areas as non-ablatable.

However, Dr. David Wilber of Loyola University Medical Center, Chicago, IL, found that patients with high levels of fibrosis can be successfully ablated by first examining the fibrotic areas for the presence of rotor circuits (i.e., A-Fib signal sources). Then, by ablating with both FIRM and high resolution optical mapping. This is a major new discovery.

Dr David Wilber Loyola University

Dr David Wilber Loyola University

In his presentation, “Impact of Atrial Fibrosis on Rotor Frequency and Location: Evidence from Combined Imaging and Mapping Studies,” Dr. Wilber beganby  examining a study by RS Oakes of 81 patients (50% had Paroxysmal A-Fib) which analyzed each patient using ‘Delayed-Enhancement Magnetic Resonant Imaging’ (DE-MRI).

Measuring Fibrotic Heart Tissue

Fibrotic heart tissue (scar tissue) is often found in patients with Atrial Fibrillation, particularly those with Persistent or Long-standing Persistent A-Fib.

DE-MRI is an MRI process which uses a metallic dye to see in 3D and identify fibrotic areas in the heart.

‘Delayed-Enhancement Magnetic Resonant Imaging’ (DE-MRI) can be used to precisely define scar tissue. As identified by DE-MRI, fibrotic heart tissue may be “low voltage”, that is, having little or no electrical activity.

In the Oakes research, “moderate” fibrosis was defined as heart tissue with 15%-35% fibrosis (low voltage) and was found in 30 patients. “Extensive’ fibrosis was defined as heart tissue with fibrosis greater than 35% and was found in 8 patients.

Fibrotic Patients and Persistent A-Fib

The Oakes study found that patients with moderate or extensive fibrosis were more frequently in Persistent A-Fib (70% vs 32%). This was true even when compared to factors such as expanded Left Atrium (LA) volume and having been in Persistent A-Fib before the ablation.

Intuitively, this makes sense. One would expect in the A-Fib remodeling process that patients with more fibrosis would be more likely to develop persistent A-Fib. (Perhaps extensive fibrosis is the reason Persistent A-Fib is harder to cure.)

Amount of Fibrosis and Recurrence Post Ablation

Dr. Wilber also discussed the DECAAF trial (see Marrouche High Fibrosis Precludes Catheter Ablation) which found fibrosis was the strongest predictor of recurrence after an ablation.

Rotors Anchored In or Located at the Edge of Fibrosis Regions

Dr. Wilber cited two additional studies. A study by BJ Hansen found that rotors are anchored to fibrotic areas of the heart. These rotor circuits can be identified and ablated by both FIRM and high resolution optical mapping. A study by McDowell found that the pattern or shape of fibrosis helps determine rotor formation.

Dr. Wilber’s Research on Left Atrium Rotors & Fibrosis

Dr. Wilber next presented his own research study. He and his colleagues used FIRM guided ablation in the examination of LA rotors and fibrosis. They first positioned the FIRM basket catheter in the right atrium and ablated rotors. They then moved to the left atrium and, after the FIRM rotor ablations, they performed a wide area circumferential Pulmonary Vein Isolation (PVI). They found more rotors (167) than focal sources (1).

Dr. Wilber and his colleagues found:

• 90% of rotor cores contained detectable fibrosis.
• The median regional fibrosis within individual rotor cores was only 13%.
• There was no relationship between the amount of fibrosis and both the number of rotors and the regional fibrosis of rotor cores.
• The mean amount of fibrosis in patients was 14.8%.

Summary and Conclusions

Summing up these research studies, Dr. Wilber concluded:

• The vast majority of rotor cores are associated with MRI detected fibrosis (90%)
• Measures of global atrial fibrosis do not predict number of identifiable rotors
• There is preferential location of rotor cores at the periphery of more dense regions of fibrosis
• Micro-anatomic distribution of fibrosis, and its impact on local electrophysiological properties, is likely to have additional influence on rotor formation, and specific sites of rotor stability.

Bottom-line for Patients with Persistent or Long-standing Persistent A-Fib

High Fibrosis Areas Can Be Ablated: While many EPs don’t ablate patients with a high level of fibrosis and consider fibrotic areas as non-ablatable, Dr. Wilber’s research shows that rotors (A-Fib signal sources) are located at or anchored in regions of fibrosis that can be ablated―particularly now that EPs know where to look for them. This may change the way mapping and ablations are done.

Good News: Patients with high fibrosis areas can be ablated.

The Amount of Fibrosis Doesn’t Predict the Number of Rotors: This is a surprising result (and needs to be confirmed by further study). This is good news for patients! Just because you have a lot of fibrosis doesn’t necessarily mean you have a lot of rotors (A-Fib signal sources). Your ablation won’t necessarily be more extensive than someone else’s.

What This Means to Patients: This fibrosis research is yet another reason for patients not to live in A-Fib! Living with A-Fib increases the risk of developing persistent A-Fib which is harder to cure. 

References for this article

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2016 AF Report: 2 Challenging, Difficult Catheter Ablation Cases with LAA Closure

AF Symposium 2016

Steve Ryan at 2016 AF Symposium

Steve Ryan at 2016 AF Symposium

Two Challenging, Difficult Catheter Ablation Cases with LAA Closure

by Steve S. Ryan, PhD

One of the most interesting and practical sessions was “Challenging Cases in Catheter Ablation and LAA Closure for AF”.  Featured were a panel with some of the world’s ‘master’ Electrophysiologists (EPs). Each presented one or two cases of their most challenging and difficult cases from the past year. The panelists were:

• Dr. David Keane, St. Vincent’s University Hospital, Dublin, Ireland (Moderator).
• Dr. Moussa Mansour, Massachusetts General Hospital, Boston, MA.
• Dr. Andrea Natale, Texas Cardiac Arrhythmia Institute, Austin, TX
• Dr. Douglas Packer, Mayo Clinic, Rochester, MN
• Dr. Vivek Reddy, Mount Sinai Hospital, New York, NY
• Dr. Miguel Valderrabano, Houston Methodist Hospital, Houston, TX
• Dr. David Wilber, Loyola University Medical Center, Chicago, IL

Two cases of Persistent A-Fib stood out as significant for readers of A-Fib.com. To learn why, see my ‘Take Away’ comments that follow each case description.

Electrically Dead Left Atrium

Dr. Miguel Valderrabano

Dr. Miguel Valderrabano

Dr. Valderrabano presented the case of a 48-year-old female patient with symptomatic Persistent A-Fib. She had been cardioverted several times and had tried several antiarrhythmic drugs including amiodarone. She had had Pulmonary Vein Isolations (PVI) by other EPs before being referred to Dr. Valderrabano.

Her left atrium was enlarged. Dr. Valderrabano ablated her again but couldn’t isolate her Left Atrial Appendage (LAA) where A-Fib signals were still coming from. He used the Lariat (SentreHeart, Inc.), a noose-like suture delivery device, to close off and electrically remove her LAA.

After these steps, she had a leak from her closed-off LAA which had to be plugged. She was A-Fib free but developed Atrial Flutter which had to be ablated.

After all these ablations, she was finally in sinus rhythm. But at what cost? All the extensive ablations and scarring had made her Left Atrium electrically dead and unable to contract normally (“Stiff Left Atrium”).

The patient knew she might lose contraction of her left atrium, but was most happy to be in sinus rhythm after years of symptomatic A-Fib.

TAKE-AWAYS FOR PATIENTS

Lariat to Prevent A-Fib Signals from the LAA: The Lariat is an occlusion device, and like the Watchman, is normally used for closing off the Left Atrial Appendage (LAA) to prevent A-Fib clots breaking loose and causing a stroke. It’s particularly useful for people who can’t or don’t want to take anticoagulants.

In this case, the LAA was the source of non-Pulmonary Vein (PV) signals (and often is). By removing it, patients can often be restored to sinus rhythm. (Master EPs now consider the LAA the most important source of non-PV triggers. Unfortunately, many EPs are unaware of the LAA’s importance and don’t check it for non-PV triggers during an ablation.)

Stiff Left Atrium: No one wants to lose their Left Atrium’s ability to contract and pump. But in extreme cases, this may happen.

I talked to one of the most experienced EPS in the world who has had to do several ablations which restored a patient to sinus but also rendered their left atrium electrically dead and unable to contract normally. [Note: the Left Ventricle does most of the heavy-duty pumping work.]

His patients, even though they knew the risks, were overjoyed to finally be in normal sinus rhythm. After years of symptomatic A-Fib, they had their life back again.

FIRM Advantages and Problems

Dr. Vivek Reddy, Mt Siani Hospital

Dr Vivek Reddy, Mt Siani Hospital

Dr. Vivek Reddy presented the case of a 63-year-old male in Persistent A-Fib who had had several ablations before being referred to him. After wearing a Holter monitor for one-week, the data showed an A-Fib burden of 27%, i.e., his A-Fib was very symptomatic and burdensome.

Dr. Reddy did a FIRM-guided ablation, but the patient was still in A-Fib.

Upon closer examination and manual mapping, the ‘renegade’ A-Fib signal source was found and ablated, which restored the patient to sinus rhythm.

Dr. Reddy had discovered the A-Fib signal in the area where the FIRM basket catheter didn’t map. As mentioned in other Symposium presentations, due to design problems, the FIRM basket catheter maps only slightly more than ½ of the left atrium. (New basket catheters to correct this problem are being developed by the manufacturer, Abbott/Topera.)

TAKE-AWAYS FOR PATIENTS

Limited but Extensive Data with Fast Results: Even though the FIRM mapping and ablation system seems to currently have built-in limitations, master EPs still use the FIRM basket mapping catheter because it provides a great deal of important information very quickly. It is especially useful in cases of Persistent A-Fib where it identifies non-PV triggers such as rotors and focal drivers. As Dr. Reddy stated earlier, this is the future of A-Fib ablation.

Choose an EP Who Can Compensate for FIRM Limitations: When choosing an EP to do your ablation, it isn’t enough to select someone who uses the FIRM system. You need an EP who knows the limitations of the FIRM system and how to find and ablate non-PV triggers the FIRM system may miss. The fact that an EP uses the FIRM system is not a guarantee you will have a successful ablation.

Wrap Up

The two cases I chose to write about were the most informative for those A-Fib patients seeking to understand the most current treatment options. This Saturday afternoon session was the last of the 2016 AF Symposium.

For more about the Lariat occlusion device, see my brief article: Lariat II Suture Delivery Device.
For more about the FIRM mapping system, see my brief article: FIRM Mapping System—Should Ablation Patients Avoid It?

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My First 2016 AF Reports: Start with 6 Live Catheter Ablations—Watching the Experts Around the World

2016 AF Symposium 5-floor-to-ceiling display screens at the Hyatt Regency Orlando

LIVE VIDEO at the 2016 AF Symposium; 5-floor-to-ceiling display screens

My first three reports from the 2016 AF Symposium are ready and posted at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

Watching LIVE Catheter Ablations

The first report is about watching LIVE catheter ablations (transmitted via the internet)—one of the most interesting and exciting features of the Symposium. Our panel of world-class electrophysiologists (EPs) were able to interact LIVE with the EPs lab doctors doing the ablations and ask questions.

The six ablations were streamed live from:

• Seoul, South Korea
• Munich, Germany
• Bordeaux, France
• Philadelphia, Pennsylvania
• Austin, Texas
• Boston, Massachusetts

On five floor-to-ceiling display screens (and additional floor monitors), I got to see the ECGI/ECVUE mapping system in action, learned about an epicardial ablation (outside the heart) to isolate an A-Fib signal from Bachman’s Bundle, and heard about an “Empirical” ablation (ablating areas known to produce A-Fib signals even though the patient is no longer in A-Fib).

Each of my summaries includes a brief patient description, treatment challenges, etc. and highlights of the procedure. I then include my personal ‘What was Most Impressive’ comments about each presentation.

Read my report at: 2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts.

And don’t miss by other reports at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

2016 AF Report: Predictors of Unsuccessful Ablations: It’s All About Remodeling

AF Symposium 2016

Predictors of Unsuccessful Ablations: It’s All About Remodeling

by Steve S. Ryan, PhD

If someone tells you to “Just live with A-Fib”, or “It’s no big deal,” or “A-Fib’s just a nuisance”, RUN, don’t walk, for a second opinion! Don’t wait—a long enough delay allows atrial remodeling to change your heart and makes it much more difficult to get a successful ablation (i.e., become A-Fib-free).

Predictors of Unsuccessful Persistent A-Fib Ablation

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre, in his presentation “Predictors of Clinical Outcomes in Ablation of Persistent AF Drivers”, found several predictors of unsuccessful ablation outcomes in persistent A-Fib cases. (Drum roll, please.) They are all related to atrial remodeling!

The predictors of unsuccessful outcomes are:

• A-Fib Duration (how long a patient had been in A-Fib prior to ablation)
• A-Fib Cycle Length (the faster the cycle length, the harder to achieve success)
• Number of Drivers (the more drivers mapped, the less chance of success)
• Arial Size (the more the left atrium is extended and stretched, the less chance of success)
• Fibrosis (being in A-Fib normally produces fibrosis)

Dr. Haissaguerre of Central Hospital, Bordeaux, France, used slides to explain his findings. (You may want to read this article together with Dr. Haissaguerre’s other presentation: Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation.)

“Reentries” are Short Lived But Recur in the Same Region

Dr. Haissaguerre showed images of ECGI/ECVUE Cardio Insight mapping done either the day before the ablation or during the procedure. ECGI produces statistical density mapping of “reentries” (rotors) and focal breakthroughs. These reentries are short lived but periodically recur in the same region.

The Number of Driver Regions

The number of driver regions increases with how long a patient has been in persistent A-Fib. In cases of long-standing persistent A-Fib, he has found as many as 7 driver regions.

Fibrosis and Low Atrial Voltage

Dr. Haissaguerre cited the work of Dr. Marrouche which found decreased ablation success with the extent of fibrosis or atrial low voltage. (For more about Dr. Marrouche’s research, see: High Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation)

Characteristics of Reentries (Rotors)

Dr. Haissaguerre discovered several previously unknown characteristic of rotors:

• Driver domains are part of CFAE areas.
• Core trajectories or rotors are anchored at distinct parts of fibrosis.
• There is a strong link of A-Fib drivers to structural heterogeneities (dissimilar parts like the PVs and LAA opening).

For example, 98% of reentries are found at common points like the Left Pulmonary Vein/Left Atrial Appendage (LAA) area. Whereas focal discharges are mainly observed at the PVs (60% of patients), LAA, or Right Atrial Appendage (RAA).

A-Fib Termination Strongest Predictor of Ablation Success

After 12 months, 85% of patients with A-Fib termination were still free from A-Fib. In the small group of patients who did not achieve termination (and were electrically shocked to try to return them to sinus), 63% were A-Fib free after 12 months. The 37% who remained in A-Fib were all patients with persistent A-Fib.

Ablation Works Best if in Sinus Rhythm Before the Ablation

The A-Fib termination rate was 84% in patients in sinus rhythm at the time of the ablation (with an RF delivery time of only 22 minutes). To get persistent patients in sinus before the ablation, they often would be electrocardioverted.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map ATs. Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”. 68% were from driver regions previously ablated. 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

How to Improve Ablation Outcomes

Dr. Haissaguerre stated that the key to improve ablation outcomes is to minimize atrial remodeling by:

1. Ablate earlier (after only a few months of persistent A-Fib, rather than letting patients go into long term persistent).
2. Restore patients to sinus rhythm before the ablation, especially in cases of longer lasting A-Fib.
3. Manage risk factors such as by using preventive drugs.

He showed slides of how flecainide reduced crucial driver regions, and how amiodarone both lengthened cycle length and decreased driver regions.

Dr. Haissaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers in a more specific way than other current approaches
• There’s a strong link of driver locations with structural heterogeneities (anatomical junctions and fibrosis)
• Predictors of clinical outcome—AF Duration, A-Fib Cycle Length, Number of Drivers, Atrial Size, Fibrosis―mainly relate to Atrial Remodeling with obvious practical implications

What Patients Need to Know

Don’t Live in A-Fib! The message for patients from Dr. Haissaguerre’s presentation is fairly obvious—Don’t settle for a life in A-Fib! A-Fib is a progressive disease that usually gets worse over time. It produces remodeling of the left atrium.

Don’t Stay in A-Fib! A delay in treatment makes it much more difficult to have a successful ablation!

Danger of a Fibrotic Heart—Fibrosis: Most of the remodeling effects of living in A-Fib can be corrected or improved by a successful catheter ablation. But not fibrosis! (Which is generally considered permanent and irreversible).

Fibrosis produces collagen and scarring in the heart which is a permanent remodeling effect of A-Fib. Fibrotic tissue is scarred, immobile, basically dead tissue with reduced or no blood flow and no transport function. It results in a loss of atrial muscle mass. Over time it makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems. Read more about fibrosis in my article: A-Fib Produces Fibrosis—Experimental and Real-World Data.

Remodeling Makes Catheter Ablation More Difficult:  A successful ablation is much more difficult when your heart has been remodeled by A-Fib. Patients with Long-standing A-Fib develop as many as seven different driver regions, compared to only two in patients who were in Persistent A-Fib for only a couple of months. Even the ‘great’ Bordeaux group couldn’t cure all of these cases.

Ground-Breaking Discoveries Important for Patients

1―Ablation works best if you are in Sinus Rhythm BEFORE the ablation.
This principle is not yet generally understood and practiced by the EP community. As a patient you should seek out EPs who will try to get you back into sinus before your ablation.

Ask the EP you are interviewing, “Will you try to get me back into sinus rhythm before the ablation?” How will you do this?” They should answer that they will use Electrocardioversion and/or antiarrhythmic drugs to do this, particularly in cases of persistent A-Fib.

For example, one A-Fib patient emailed me that the Mayo Clinic Electrocardioverted her into sinus, then used Tikosyn to keep her in sinus for a month or two before her ablation.

2―A-Fib termination is the strongest predictor of ablation success.
This discovery is very important for patients. Some previous research said that it really didn’t matter if A-Fib terminated during the ablation.

Nevertheless, in Dr. Haissaguerre’s research, 84% of patients with A-Fib termination during the ablation procedure were still free of A-Fib after 12 months.

The Bottom line for Patients

A-Fib termination during the ablation procedure should be the goal of every EP. You should seek out EPs who will make that extra effort (such as replacing the CryoBalloon catheter with a RF catheter to isolate non-PV triggers). All too many EPs aren’t willing or aren’t able to do that.1

Dr. Michel Haïssaguerre

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

Citations for this article

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References    (↵ returns to text)

  1. I recently read an O.R. report where the EP used CryoBalloon ablation on a patient in persistent A-Fib for two months. They successfully isolated the patient’s Pulmonary Vein openings (PVs), but the patient was still in A-Fib. Instead of trying to map and isolate the patient’s non-PV triggers which were still producing A-Fib signals, the EP simply shocked the patient back into sinus rhythm. After a few weeks, the patient was back in A-Fib again. (But to be fair to the EP, sometimes this is successful.)

2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts

AF Symposium 2016

Six Live Catheter Ablations—Watching the Experts

by Steve S. Ryan, PhD

2016 AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

2016 AF Symposium 5-floor-to-ceiling video monitors

Watching LIVE catheter ablations on floor-to-ceiling display screens was one of the most interesting and exciting features of the AF Symposium. “Case Studies: Catheter Ablation for Atrial Fibrillation” featured live streaming video (transmitted via the internet rather than by satellite as in previous years).

The six ablations were streamed live from:Live Streaming Video from 2016 AF Symposium

• Seoul, South Korea
• Munich, Germany
• Bordeaux, France
• Philadelphia, Pennsylvania
• Austin, Texas
• Boston, Massachusetts

A world-class panel of electrophysiologists (EPs) were able to interact with the EPs doing the ablations and ask questions.

The panelists were: Dr. Moussa Mansour (Co-Moderator), Dr. Jeremy Ruskin (Co-Moderator), Dr. Michel Haissaguerre, Dr. Francis Marchlinsk,i Dr. Andrea Natale, Dr. Douglas Packer, Dr. Vivek Reddy and Dr. David Wilber.1

The Live Cases Begin

Seoul, South Korea: 62-year-old in long-standing persistent A-FibLive Seoul S Korea

Drs. Young-Hoon Kim, Jong-II Choi, JaeMin Shim and their colleagues from S. Korea were all wearing radiation glasses. They were doing a very difficult case of a 62-year-old in long-standing persistent A-Fib for 12 years. He had had a previous ablation. But his A-Fib had recurred five months ago.

His PVs were well isolated. They worked on ablating CFAEs, the right atrium, and the septum which was very fibrotic.

Very unusual: an epicardial ablation (outside the heart) to isolate an A-Fib signal from Bachman’s Bundle.
What was very unusual was they performed an epicardial ablation (outside the heart) to isolate an A-Fib signal they found coming from Bachman’s Bundle. (We didn’t get to actually see that, due to the audio problem.)

When they ablated the Left Atrial Appendage, the A-Fib terminated.

What Was Most Impressive

• Ablating from outside the heart. As far as I know, very few EPs do this. Should every EP receive training in ablating from outside the heart? What’s the best way of discovering and mapping A-Fib signals coming from the exterior of the heart, such as from Bachman’s Bundle? (I’ve written the S. Korean EPs to ask them these questions.)

• Successfully ablating and terminating A-Fib in someone who had been in long-standing persistent A-Fib for 12 years. This is usually the most difficult kind of case and the hardest to cure. (Many EPs would consider this long-standing persistent case unfixable and not even attempt a catheter ablation.) It’s no surprise that this was the second ablation for this patient. This case also shows the importance of the Left Atrial Appendage (LAA) in A-Fib ablation.

Munich, Germany: 62-year-old male in long-standing persistent A-Fib and BMI of 35Live Munich Germany

Drs. Isabel Diesenhofer, Felix Bourier and Tilko Reents of the German Heart Center in Munich did an ablation on an unusual case, a 62-year-old male in long-standing persistent A-Fib with a BMI of 35! (Many centers would not accept this patient for an ablation without his first losing weight.)

Dr. Diesenhofer said they don’t use Contact Force sensing catheters because they are too soft. They don’t use TEE but instead use CT to check for clots and to see where the esophagus is in relation to the back of the heart. They perform circumferential PVI.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity. Their goal is to terminate A-Fib during the procedure, but 70%-80% of these cases come back in Atrial Tachycardia (AT). A second ablation is usually more successful.

They found that the fastest frequencies were coming from the patient’s LAA. When they terminated A-Fib, they used adenosine to test for recurrence.

What Was Most Impressive

• I was surprised that they were doing an ablation on someone with a BMI of 35! The chances of recurrence are huge when someone is obese.

• The use of adenosine after termination of the patient’s A-Fib in order to try to re-induce A-Fib and test for ablation integrity and isolation.

• And, as in the live case from South Korea, this case showed the importance of the LAA in A-Fib ablation, particularly in persistent A-Fib.

Bordeaux, France: 40 year old who went directly into persistent A-FibLive Bordeaux France

Dr. Mélèze Hocini, Bordeaux, France worked behind what looked like a Plexiglas screen with arm holes as a protection against radiation. Her patient was unusual in that he was relatively young, 40 years old, who went directly into persistent A-fib without apparently having paroxysmal (occasional) A-Fib first. He had undergone 3 cardioversions. He was symptomatic, especially dyspnea. He had tried Sotalol and Flecainide.

The day before his ablation, he was mapped with the ECGI/ECVUE Cardio Insight vest. Dr. Hocini showed how the vest mapped four basic areas where there were rotors/focal drivers. She had circled each area and gave each one a priority number from 1 to 4 depending on how many rotors/foci there were in each section.

We watched as she ablated the first area. She ablated at 40 watts for 30 or 40 seconds. The LAA had the highest frequency 167. (In general, they try to slow down the frequency to 200 which usually results in termination.)

An important innovation developed by the Bordeaux group is to re-map during the procedure.

An important innovation the Bordeaux group has developed is to re-map during the procedure. Sometimes new signal areas may appear which need to be ablated. Dr. Hocini, re-mapped, but didn’t find any new signal areas. This patient had many CFAEs (70%). The drivers covered 30% of his left and right atria.

Someone mentioned that the Pentaray mapping catheter was faster and provided better definition than ECGI. Non-PV triggers are often found in the septum, anterior left atrium, coronary sinus, and the left and right appendages. The goal is to slow down the frequency and make the signals more organized.

After a visit with the teams in Philadelphia and Austin, the moderators returned to the group in Bordeaux, France.

Eeveryone was relaxing and happy. While we were away, Dr. Hocini had ablated the third area of rotors/foci which terminated the A-Fib and restored the patient to sinus rhythm.Since the patient was already in sinus, Dr. Hocini didn’t ablate the remaining fourth area of rotors/foci.

What Was Most Impressive

• It was simply amazing to see ECGI/ECVUE in action! To me it looked like I was seeing the future of A-Fib ablation. Dr. Hocini seemed almost nonchalant, like she had done this many times before and was confident it would work. Like many great innovations, using ECGI seemed very simple.

Philadelphia, Pennsylvania:  76-year-old woman with hypertension, persistent A-Fib for five years and previous PVILive Philadephia PA

The moderators then switched to Drs. David Frankel, Pasquale Santangeli, and Gregory Supple at the Un. of Pennsylvania in Philadelphia. They were ablating a 76-year-old woman with hypertension who had been in persistent A-Fib for five years. (Usually a more difficult case.) She had had a Cardioversion in 2014. She was on amiodarone but was still severely symptomatic.

In their experience, ablating only the PVs returns patients to sinus in 80% of all types of A-Fib. They find non-PV triggers in many different sites in the left and right atria. Their protocol is to do a PVI, cardiovert, ablate, then use isoproterenol to induce or re-induce A-Fib triggers.

…a somewhat unusual strategy called “empirical” ablation…Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

This patient also had had a previous PVI, but two of her PVs were re-connected and needed to be ablated. She was restored to sinus rhythm. They then used isoproterenol to try to re-induce A-Fib.

They also employed a somewhat unusual strategy called “empirical” ablation. From their experience, they know that certain sites in the atria tend to produce non-PV A-Fib signals. Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

What Was Most Impressive

• “Empirical” ablation (ablating areas known to produce A-Fib signals even though the patient is no longer in A-Fib) is a somewhat controversial strategy. Some would say one shouldn’t scar or burn the heart unless those areas are actually producing A-Fib signals or potentials. Scarring does damage heart tissue. Personally, I would prefer to have them ablate these “empirical” sites as long as they are in my heart anyway.

• In contrast with the Munich, Germany case, the EPs in the Un. of Pennsylvania used isoproterenol to try to re-induce A-Fib rather than adenosine.

Austin, Texas: 83-year-old woman in long-standing persistent A-FibLive AUSTIN TX

The moderators then switched to Drs. Rodney Horton, Amin Al-Ahmad, and J. David Burkhardt at the Texas Cardiac Arrhythmia Center in Austin, TX. They didn’t use any fluoroscopy during their ablation and weren’t wearing the standard-issue lead vests to protect from radiation. They used ICE for navigation.

Their patient was an 83-year-old woman in long-standing persistent A-Fib. Even though she was very symptomatic, she was very active and was scheduled to be married in a couple of weeks. She had been on amiodarone and had failed cardioversions. She had a lot of severe scarring.

They stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA.

They cardioverted her two times without success. After their first ablation, they used isoproterenol to check for re-connection. Two of the PVs had reconnected and had to be re-isolated. Their next step was to isolate the LAA. But they stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA. This patient knew that she could lose her LAA, that later they may have to physically remove it, and that this might affect her.

She still wanted it done so that she could be restored to sinus rhythm. For her it was better long term to be free of A-Fib than to retain a LAA.

They did electrically isolate her LAA and restored her to sinus rhythm, which she hadn’t been in in many years.

What Was Most Impressive

• Though we had seen this last year in the live cases, it was still something of a shock to see EPs, nurses and staff not wearing any protective gear against radiation. (When I visited an A-Fib lab to watch an ablation, I had to wear a very heavy lead vest and other protective gear.) They use ICE instead of fluoroscopy (X-ray) to manipulate the catheters.

• You will notice that this is the third live case emphasizing the importance of the LAA, particularly in persistent A-Fib. They discussed with this patient the possibility that she might lose her LAA. But like most A-Fib patients, she was willing to take that risk to be free of A-Fib

Boston, Massachusetts: 65-year-old male with atypical FlutterLive BOSTON MA

The moderators then switched to Dr. Kevin Heist at Massachusetts General Hospital in Boston. He was working on a case of atypical Flutter. A 65-year-old male patient had been symptomatic for many years. He had tried flecainide. In 2003, he had a PVI. Then in 2010 he had to have a re-do which kept him in sinus rhythm for 5 years. In 2015 he had a cardioversion but still had atypical flutter. His ejection fraction was a very good 75%, but he had mild left atrial enlargement. They found that his PVs and posterior atrium wall were still well isolated.

Biosense Webster PentaRay catheter

The Biosense Webster PentaRay catheter

They demonstrated how to use the PentaRay NAV mapping and ablation catheter (Biosense Webster) to very rapidly map the atrium. It uses a multi-electrode mapping technology. The five branch star design has branches that are soft and flexible so as not to damage the heart surface.

Through pacing, Dr. Heist found a Mitral Annulus Flutter, which he ablated. This terminated the Atrial Tachycardia and restored the patient to sinus.

What Was Most Impressive

• It was fascinating to watch the PentaRay catheter rapidly move by itself over the heart. It kind of looked like a spider crawling along inside the heart. It was amazing how fast the PentaRay catheter reproduced and mapped the heart automatically in high resolution. Very few moves were necessary to map the whole left atrium.

• Is the PentaRay NAV mapping catheter better than the FIRM or ECGI/ECVUE systems? Should one seek out a center using the PentaRay catheter? Right now we can’t say for sure. As far as I know, there haven’t yet been any comparative studies of the PentaRay mapping catheter compared to FIRM or ECGI. Most likely it will eventually be used in combination with FIRM or ECGI. It seems like an important tool and advance in mapping.

That’s a WrapThats a Wrap on TV monitor 215 x 200 pix at 300 res

The co-moderators, Dr. Moussa Mansour and Dr. Jeremy Ruskin (both from Mass. General Hospital, Boston,MA) did a good job moving the program along and kept the interactions with the EP labs personnel on point.

It’s awesome to watch the world’s best electrophysiologists restoring patients to normal sinus rhythm and making them A-Fib-free.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, February 11, 2016

References    (↵ returns to text)

  1. An audio problem caused a delay at the start of the program. During the wait, the panelists spoke about their work with persistent A-Fib. Dr. Marchlinski said that at the Un. of Pennsylvania 11% of male patients have non-PV triggers while 16% of females have them. (However, he uses a more conservative, stricter definition of an A-Fib trigger.) Whereas Dr. Reddy said that at Mount Sinai Hospital, 30% have non-PV triggers.

    Dr. Vivek Reddy considers the mapping and ablation of non-PV triggers to be the next step in the evolution of catheter ablation of A-Fib. (This is perhaps the most important statement made at this AF Symposium.)

    Both Dr. Reddy and Dr. David Wilber (Loyola, IL) use the FIRM mapping system among other mapping strategies. (ECGI/ECVUE is not currently available in the US.)

Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation

AF Symposium 2016

Bordeaux New ECGI Ablation Protocol—Re-Mapping During Ablation

by Steve S. Ryan, PhD

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

Why should patients be interested in a new mapping and ablation technique that isn’t yet available worldwide and in the US?

Why ECGI/ECVUE is Important

ECGI/ECVUE is probably the most significant, game changing improvement in treating A-Fib (along with Contact Force sensing catheters), particularly for people with persistent A-Fib.

ECGI will not only change the ways mapping and ablations are done, but possibly how you and I are examined and diagnosed in our doctor’s office.

Image a Future Physical Without an EKG

Imagine when you go in for a physical that, instead of getting an EKG, you simply put on an ECGI vest which tells the doctor where and how many A-Fib producing potentials you have in your heart, all without you having to be in A-Fib. Admittedly, this is pie-in-the-sky speculation right now. But the ECGI vest has tremendous potential to change the way A-Fib is diagnosed and treated.

Dr. Michel Haissaguerre & New Uses of ECGI/ECVUE

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France presented new developments in how the Bordeaux group now uses ECGI/ECVUE Cardio Insight body surface mapping for persistent A-Fib. His talk was entitled “Monitoring of AF Drivers During Catheter Ablation for Persistent AF.” (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging [ECG]). See also How ECGI Works.)

Patient Prep with the ECGI Vest

Typically, the day before an ablation, a technician (it doesn’t have to be the EP ablationist) uses a ECGI vest to map and identify sites in the heart producing A-Fib signals (rotors and focal sources). The next day, using this map combined with a CT scan which produces a very detailed 3D color map of the heart, the EP ablates and isolates these sites.

What’s New: Bordeaux Group Also Re-Maps Using the ECGI Vest

What’s brand new about how the Bordeaux group is using ECGI is that, if a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest. This often reveals missed, changed or new A-Fib drivers. They then ablate/isolate these regions.

If a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest.

The ideal or goal is for A-Fib to terminate into sinus rhythm or Atrial Tachycardia (AT). Atrial Tachycardia (a heartbeat that is in sinus rhythm but faster than normal) can then also be mapped and ablated into Normal Sinus Rhythm (NSR). (Atrial Tachycardia, for the average persistent patient, feels a lot better than being in A-Fib.)

If after re-mapping and ablation, the patient is still in A-Fib, they use Electrocardioversion to try to shock the patient back into sinus.

See the AF Symposium Live Case Presentations: Dr. Mélèze Hocini of the Bordeaux group ablated a 40-year-old male with persistent A-Fib. She found four areas of rotor/focal activity in his heart. After ablating the third area, the patient’s persistent A-Fib terminated. Dr. Hocini did not have to re-map or ablate the fourth area.)

Slides of Before and After ECGI Ablation

Dr, Haissaguerre showed slides of before and after an ablation using ECGI. Ablation at a driver region transformed rapid, complex signals into slower, organized signals.

In the AFACART study in which eight different centers used the ECGI system, ablations in driver regions varied from 38 to 98 minutes of cumulative RF energy delivery time per center despite similar patients and targets (indicating the current lack of standardized ablation techniques). (For more on the AFACART study, see AF Symposium 2015: AFACART Clinical Trial.)

Persistent A-Fib Case: In the case of a 48-year-old female in Persistent A-Fib for four months, four target areas were identified: the inferior Left Atrium (LA), the LA Septum, the anterior of the LPV (Left Pulmonary Vein) to the LAA, and the posterior area of the RPV (Right Pulmonary Vein). (They divide the left and right atria into seven general physical areas.) A-Fib continued after these driver areas were ablated. On re-mapping, the septum area was found to be still active. After 2 more minutes of RF delivery to that septum area, A-Fib terminated into normal sinus rhythm.

Ablation Failure From Thicker Atrial Tissue?

Dr. Haissaguerre pointed out that ablation failure happens particularly in the right and left atrial appendages because of thicker atrial tissue. He showed a slide where he ablated one driver area, then six months later ECGI showed a new driver region at the LAA ridge.

Right Atrium Drivers Reduced After Left Atrium Ablation

Next, he showed slides where the ECGI mapping system initially showed driver activity in the Right Atrium (RA). But after Left Atrium (LA) ablation, this driver activity was greatly reduced. He suggested that RA drivers might mirror or be a projection of LA drivers.

Right Atrium drivers might mirror or be a projection of Left Atrium drivers.

(This is a new research finding that may be very important and may change the way the right atrium is ablated in persistent A-Fib cases.)

ECGI After Prior Extensive PVIs

Dr. Haissaguerre showed slides of patients who had had two or three prior PVIs. ECGI clearly showed where there were still driver regions. Each patient’s persistent A-Fib was terminated into normal sinus rhythm.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map Atrial Tachycardias (AT). Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”; 68% were from driver regions previously ablated; 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

Limitations of ECGI NonInvasive Driver Mapping

According to Dr. Haissaguerre:

• Body filtering (ECGI) may miss small local AF Signals, while showing the main propagating waves in a panoramic scope
• Extensive ablation may affect egm (electrogram) quality and analysis
• Besides ‘drivers’, other mechanisms of AF perpetuation may coexist, particularly in longer lasting (>1 year) AF

Dr. Haissaguerre’s Conclusions

• Remapping can confirm elimination or persistence of drivers or show new drivers (requiring further ablation)
• This dynamic information will probably increase the rate of AF termination
• Further improvement expected with rapid mapping of Atrial Tachycardias

What Patients Need to Know

The ECGI/ECVUE Cardio Insight body surface mapping seems like a major improvement and development, particularly for patients in persistent A-Fib, usually the hardest to cure.

ECGI is probably the most significant, game changing improvement in the treatment of A-Fib (along with Contact Force sensing catheters).

This ECGI system is being carefully developed in eight centers in Europe (AFACART clinical trial). It was recently purchased by Medtronic and is headquarted in Dublin, Ireland.

(No one at the Medtronic booth at the AF Symposium exhibit hall could tell me when the ECGI system will be available for examination and use in the US and worldwide. I’ll update this report when I know.)

Re-Mapping a Major Improvement in ECGI: We’re grateful to Dr. Haissaguerre and the Bordeaux group for developing the technique of re-mapping during an ablation. It’s certainly a major improvement in what was already a very good mapping and ablation system.

Mapping and Ablating Atrial Tachycardias (ATs): From a patient’s perspective, it’s great to know that ECGI can be used to identify and ablate atrial tachycardias (fast heart rates).

A-Fib termination can result in normal sinus or ATs which are a form of sinus rhythm. For most people, ATs are certainly better than being in A-Fib. But they can be annoying and disruptive. It’s good to know they can be mapped and ablated just like A-Fib signals.

ECGI May Miss Small Local ATs and A-Fib Signals: ECGI isn’t perfected yet. Dr. Haissaguerre showed that many of the local ATs found came from driver regions previously ablated.

DR. MICHEL HAÏSSAGUERRE

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, February 11, 2016

2016 AF Symposium: In-depth Reports for Patients by Steve S. Ryan, PhD

Steve Ryan at 2016 AF Symposium

Steve Ryan at 2016 AF Symposium

AF Symposium 2016

My Summary Reports Written for A-Fib Patients

by Steve S. Ryan, PhD

Each year I attend the AF Symposium to get a thorough and practical view of the state of the art in the treatment of A-Fib. My goal is to offer patients the most up-to-date A-Fib research and developments that may impact their treatment choices.

Note: My most recent reports are listed first.

REPORT TITLE PRESENTER (S) DATE POSTED
7. Thickening of Left Atrium and Amount of Fibrosis Predicts Outcome of A-Fib Ablation Dr. Nassir F. Marrouche, University of Utah, Salt Lake City, UT Feb. 22, 2016
6. Hot Topic—Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib Dr. David Wilber of Loyola University Medical Center, Chicago, IL Feb. 14, 2016
5. Two Challenging, Difficult Catheter Ablation Cases with LAA Closure Dr. David Keane, St. Vincent’s University Hospital, Dublin, Ireland (Moderator); Drs. Vivek Reddy and Migel Valderrabano Feb. 12, 2016
4. Predictors of Unsuccessful Ablations: It’s All About Remodeling Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France Feb. 11, 2016
3. Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France  Feb. 10, 2016
2. 2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts Dr. Moussa Mansour and Dr. Jeremy Ruskin, co-moderaters, Mass. General Hospital, Boston,MA  Feb. 9, 2016
1. 2016 AF Symposium Overview by Steve S. Ryan, PhD – – – Feb 8, 2016

“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: Tuesday, February 9, 2016

Steve’s 2016 AF Symposium Reports: For the Most Recent Advances in A-Fib Treatments

Want the latest on emerging treatments for Atrial Fibrillation? The most recent research findings? From the best in the world? Me too! That’s why I attend the annual AF Symposium held each January in Orlando, FL.

Steve Ryan at the 2016 AF Symposium, Jan 14-16.

Steve Ryan at the 2016 AF Symposium, Jan 14-16.

The 2016 AF Symposium brought together the world’s leading cardiologists, medical researchers and scientists to share the most recent advances in the field. It is one of the most important medical conferences on Atrial Fibrillation in the world.

What this Means to You

My aim is to pare down the significant research findings to the essentials and ‘translate’ them into plain language (as much as possible) for A-Fib patients and their families. I then add my own comments and insights.  

You won’t find this information in this format anywhere else.

My Overview and First Reports

Begin with my Overview. Find out what was the Most Discussed topic! And the Most Controversial topic! I also give you a few highlights and a list of conference topics. Look for my first summary reports starting later this week.

Start here: go to my AF Symposium Overview.

2016 AF Symposium Overview

Steve Ryan at the 2016 AF Symposium

Steve Ryan at the 2016 AF Symposium

Mechanisms and New Directions in Therapy, January 14-16, 2016, Orlando, FL

by Steve S. Ryan, PhD, February 9, 2016

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

Why I Attend

Each year I attend the AF Symposium to learn and ‘absorb’ the presentations and research findings. Attending the sessions gives me a thorough and practical view of the current state of the art in the field of A-Fib. I then sort through this newly acquired knowledge and understanding for what’s relevant to patients and their families. Over the next months, I will try to post 20–35 reports on my website, A-Fib.com.

The Venue: Hyatt Regency Orlando

The 2016 AF Symposium was held at the 4-star Hyatt Regency Orlando hotel in Orlando, Florida.

The scientific session presentations were held in the huge Windermere Ballroom equipped with five floor-to-ceiling display screens with additional floor monitors and perfect audio from any seat. the ballroom’s temperature was comfortable (and not too cold/hot like last year.)

5-floor-to-ceiling video monitors at the Hyatt Regency Orlando: 2016 AF Symposium

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

An improvement from last year was the separate Exhibition area just down the hall. (Last year the sound from the exhibit area intruded into and disrupted the scientific sessions’ presentations.) Everything ran smoothly (except the initial audio of the first live case presentation.) and included satisfying lunches and break refreshments.

With the room rates starting at $129/night and parking at $18.00/day, I stayed at the Motel 6 nearby ($30.00 per night with an AARP card discount) and happily was able to park nearby for free.

News & Views from the 2016 AF Symposium

The dominant mood or feeling of the 21st AF Symposium was a sense of or awareness of ‘dynamic, incremental, focused change’ coupled with heated controversy over rotors.

Each day started at 7:00 AM and finished around 6 PM (Saturday adjourned mid-afternoon to enable catching evening flights home.)

Short Sessions

There were 55 different short presentations (10 or 15 minutes) by 56 A-Fib experts and researchers from around the world. Each talk was usually followed by a Q&A with audience members.

Every seat was equipped with an interactive audience response device so each attendee could enter their answer to any multiple choice question posed by presenters. The results were then flashed up on the screen for further discussion.

Lightning Rounds

Some sessions were followed by “Lightning Rounds” on a particular problem or question. Panelists and the audience could answer the question or share how their facility handles that particular problem. For example, “Which patients should have their Left Atrial Appendage closed off?” or “How do you protect the esophagus during an ablation?”

Live Ablation Cases via Streaming Video: Worth the Price of Admission

Live Streaming Video 245x200 pix at 300 resThere were six live video presentations (via internet streaming video) of ablations from centers around the world:

• Seoul, S. Korea
• Munich, Germany
• Bordeaux, France
• Austin, Texas
• Philadelphia, Pennsylvania
• Boston, Massachusetts

As usual, these live case presentations were worth the price of admission.

The presentation of the live case from Korea had to be postponed for a while until they could work out a technical problem with the audio. (Having worked in broadcast television for 16 years, I know you can have a perfect test run but have something go wrong during the live event.)

Topics Overview

To give you a sense of the scope of subjects covered at this AF Symposium, each of the following eleven session topics had 6-9 different talks relating to that subject:

• New Insights into the Pathophysiology, Genetics and Epidemiology of AF— The Science and Mechanisms of A-Fib
• Frontiers in Atrial Fibrillation—Management of A-Fib Patients
• Challenging Cases in AF Management: Anticoagulant Drugs, Anticoagulation, and Clinical Decision Making
• Clinical Trials and Regulatory Issues in AF Ablation—Featuring Presentations by the FDA
• Left Atrial Appendage Closure: Devices, Techniques and Clinical Outcomes—Probably the Second Most Important Topic of this AF Symposium
• Case Presentations: Catheter Ablation for Atrial Fibrillation—Six Live Cases
• Optimizing the Safety and Effectiveness of Pulmonary Vein Isolation Part I and Part II
• Anticoagulation Part I and II: A New Era in Pharmacological Stroke Prevention in Atrial Fibrillation
• Advances in Catheter Ablation for Persistent AF: Mechanisms, New Tools and Outcomes
• Rotors and Other Mechanisms in Persistent AF: Concepts and Controversies—The Most Hotly Discussed Topic in this AF Symposium
• Challenging Cases in Catheter Ablation and LAA Closure for AF

The Most Discussed

The most discussed and argued about topic was non-PV triggers/drivers/rotors.

The most important and historically significant statement made at this AF Symposium was by Dr. Vivek Reddy of Mount Sinai Hospital in New York City:

“The mapping and ablation of Non-PV Triggers is the next step in the evolution of catheter ablation of atrial fibrillation.”

The Most Controversial

The most important and controversial session was Saturday morning’s “Rotors and Other Mechanisms in Persistent AF: Concepts and Controversies.”

 The panel discussions about rotors became very heated.

It was somewhat disconcerting to hear some cardiologists argue that rotors don’t exist. Dr. Waldo: “I don’t find any rotors.” Dr. Allessie: “If you see rotors, they are wrong.”

Yet during the three days of the Symposium, rotors were the subject of many presentations. The new mapping systems like FIRM and ECGI/ECVUE map, identify and ablate rotors. I kept asking myself how can they say that rotors don’t exist?

Steve at 21st Annual AF Symposium in Orlando FL

Steve at 21st Annual AF Symposium in Orlando FL

The panel discussions about rotors became very heated. A possible reconciliation occurred when Dr. Allessie stated that rotors and breakthroughs can coexist. One drives the other.

Dr. Karl-Heinz Kuck added to the confusion and controversy when he showed a different but similar type of ECGI vest that he uses to map rotors. He doesn’t get the same results as the Bordeaux group and Dr. Haissaguerre.1

As Dr. Jose Jalife summed up:

“For the first time in 20 years, we are talking about mechanisms rather than being ‘anatomicalists’.”

Dynamic, Incremental, Focused Change

Though this is a very subjective non-scientific view, to me the dominant mood or feeling of this year’s AF Symposium was a sense of or awareness of ‘dynamic, incremental, focused change’ coupled with heated controversy over rotors.

The Next AF Symposium: The 2017 AF Symposium will also be at the Hyatt Regency Orlando, January 12-14, 2017.

My Summary Reports

Look for my first summary reports starting later this week.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

 If you find any errors on this page, email us. Y Last updated: Saturday, May 21, 2016

References    (↵ returns to text)

  1. I couldn’t tell if Dr. Kuck was speaking tongue-in-cheek or was really serious when he added: “I burn and nothing happens. I don’t understand how to ablate.” Then he said he was stopping ablations until he knew how. (No one in the room knew if he was kidding or not.)

The 2016 International AF Symposium: Research You Can Use

Sunday I returned home from four days in Orlando, FL, and the 21st Annual AF Symposium.

Why I Attend the International AF Symposium

The AF Symposium brings together the world’s leading cardiologists, medical researchers and scientists who share the most recent advances in the field. It is one of the most important medical conferences on Atrial Fibrillation in the world.

AF Symposium SSR 400 pix wide at 300 res

Steve Ryan at the 2016 AF Symposium

Each year I attend to listen, learn and ‘absorb’ the presentations and research findings. (I take loads of notes.) The conference gives me a thorough and practical view of the state of the art in the treatment of Atrial Fibrillation (A-Fib).

After each presentation, I ask myself: “What does this mean to A-Fib patients?” “How might this impact the treatment decision patients are making now and in the future?” “What will my A-Fib.com readers what to know about?”

What This Means to You

My aim is to pare down the significant research findings to the essentials and ‘translate’ them into plain language (as much as possible) for A-Fib patients and their families. I then add my own comments and insights.

“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, Mass. General Hospital & Harvard Medical School

On the plane ride home, I start a summary of the conference and an overview of the most popular topics or issues.

In the months following the Symposium, I write and post three or four reports each month usually ending up with about 20–30 articles. (Why does it take so long? I send each summary to the presenter inviting their feedback; so it takes some time to get each article written, reviewed, and then posted.)

My Reports are Coming Soon

My reports are written just for A-Fib patients and their families. You won’t find this information in this format anywhere else. (BTW: physicians, cardiologists and electrophysiologists read my reports, too.)

I will post my Symposium Overview soon followed by my first eight reports.

To learn more: If you want to review my 2015 AF Symposium reports, see 2015 AF Symposium Reports by Steve S. Ryan, PhD; For more about the AF Symposium see: What is the Annual ‘AF Symposium’ and Why it’s Important to Patients

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