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


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

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

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

Jill and Steve Douglas, East Troy, WI 

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

Faye Spencer, Boise, ID, April 2017

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

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


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


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"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

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

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

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


Significant Research and Scientific Studies

Catheter Ablation vs Surgery For A-Fib: Finally an Apples-to-Apples Comparison

Update July 27, 2018 Which is better from a patient’s perspective―Catheter Ablation or Surgery (Mini-Maze)? A new study compares the two head-to-head.

An article in Cardiac Rhythm News (no author), describes the SCALAF trial (Surgical vs. Catheter Ablation of paroxysmal and early persistent Atrial Fibrillation).

SCALAF Trial Design

The SCALAF study is the first randomized control trial of patients with symptomatic A-Fib. In a 1:1 ratio, 52 patients received either a catheter ablation or surgery as their first invasive procedure. Follow-up data in all patients was collected for 2 years using implantable loop recorders (Medtronic Reveal XT).

The measurement of success was freedom from A-Fib (atrial tachyarrhythmia) and off antiarrhythmic drugs with safety measured by procedure-related complications.

PV Isolation Direct Comparison: The catheter ablation arm only isolated the PVs without additional lesion sets. The surgical arm (Mini-Maze) only isolated the PVs (and removed the left atrial appendage).

Trial Results

Efficacy: Catheter ablation vs. surgical patients (60% vs. 27%) were free from A-Fib without drugs.

Efficacy: After 2 years, a significantly greater number of catheter ablation patients (60%) were free from A-Fib without having to take A-Fib drugs compared to a much smaller number of surgical patients (27%).

Safety: Surgery patients had a higher procedure-related complication rate (34.8% vs. 11.1%) and a higher rate of major complications (22% vs. 0.0%) compared to catheter ablation patients. That’s about 1-in-4 surgical patients who had significant complications.

Safety: Surgery patients had a higher procedure-related complication rate (34.8% vs. 11.1%).

Hospital Stay: Hospitalization was longer for surgical patients with an average hospital stay of nine (6–10) days compared to three (2–3) days for catheter ablation.

Trial Conclusions

The investigators concluded that catheter ablation of the PVs in the treatment of paroxysmal and early persistent A-Fib is safer and results in higher long-term arrhythmia free survival compared to surgical (Mini-Maze) PV isolation. Follow-up with continuous monitoring using implantable loop recorders was important for true and accurate outcomes.

What Patients Need to Know

Don’t Make Surgery Your First Choice: Following the 2014 Guidelines for the Management of Patients with Atrial Fibrillation, your first treatment option should not be surgery (Mini-Maze).

Catheter Ablation Higher Success and Safer: Though this was a small study, this trial showed that catheter ablation is safer with better long-term freedom from A-Fib (and without medication) when compared head-to-head with surgical Mini-Maze. Follow-up monitoring of each patient with an implantable loop recorder (for 24/7, 365 days for two years) produced unbiased, non-disputable results.

The 2011 FAST Trial: The SCALAF trial results might be compared to the 2011 FAST Trial sponsored by AtriCure, Inc. The FAST trial compared AtriCure’s own system for Mini-Maze surgery to catheter ablation. The results favoring surgery don’t hold up under close scrutiny. More important was the high complication rate of the surgical approach. For more, see Surgical Versus Catheter Ablation―Flawed Study.

SCALAF: Catheter ablation is safer with better long-term freedom from A-Fib (and without medication) when compared head-to-head with surgical Mini-Maze.
 The Bottom Line: We now have an unbiased clinical trial comparing catheter ablation with surgery.

According to the SCAFAL trial, catheter ablation has higher success for long-term freedom from A-Fib than the surgery approach. Just as important, data from both FAST and SCAFAL demonstrate that catheter ablation is much safer than surgery.

Update July 27, 2018: In response to this post about the SCAFAL trial, we received this statement from surgeon Dr. John H. Sirak who performs the “5 box surgery” for A-Fib. Especially relevant is his statement that surgical PVI alone tends to produce Flutter. (The FAST study did compare more complex surgeries to catheter ablation.)

“I must be direct and say this study is next to worthless. First, it isn’t clear how the cohorts compare in terms of AF chronicity. Surgical PVI should at least be no worse than percutaneous. PVI is the most foolproof step of a surgical maze. If the randomization were truly accurate, why was the surgical arm so much smaller? My suspicion is that the surgical arm had a significantly higher number of non-paroxysmal patients. And who were the orangutans operating with a 35% complication rate? Along the same lines, since surgical PVI alone is now widely known to be fluttergenic and thus contraindicated, no reputable surgeon would offer a patient such an outdated operation! This study is not only pathetically executed, but also has no relevance to current standard-of-care practice.” 
Resources for this article
• Surgical treatment of atrial fibrillation results in higher complication rates when compared to catheter ablation. Cardiac Rhythm News (no author). May 18, 2018, Issue 41, p. 9.

• Surgical or Catheter Ablation of Lone Atrial Fibrillation (AF) Patients (SCALAF). ClinicalTrials.gov Identifier: NCT00703157. Sponsor: Medtronic Bakken Research Center Note: Principal Investigators are NOT employed by the organization sponsoring the study. https://clinicaltrials.gov/ct2/show/results/NCT00703157.

• AHA/ACC/HRS 2014 Guideline for the Management of Patients With Atrial Fibrillation. Circulation. published online March 28, 2014, 4.2.1. Antiplatelet Agents, p 29.doi: 10.1161/CIR.0000000000000041 Last accessed Nov 23, 2014.URL: From http://content.onlinejacc.org/article.aspx?articleid=1854230

Catheter Ablation Compared to Amiodarone Drug Therapy in Heart Failure Patients with A-Fib

Background: I previously reported on the ground-breaking CASTLE-AF study published in 2018 which compared treatment with conventional antiarrhythmic drugs (both rate and rhythm control) versus treatment with catheter ablation. I recently came across another, similar study. While the 2016 AATAC study pre-dates the CASTLE-AF study, it also contributes to our understanding of treatment choices for heart failure patients with A-Fib.

Treating Patients with Both Heart Failure and A-Fib

Heart failure is very common in patients with A-Fib (estimated at 42%). These are very sick patients. For people with advanced heart failure, nearly 90% die within one year.

In patients with both conditions, a cardiologist’s first treatment is most often drug therapy with an antiarrhythmic drug. But is this an effective strategy? Is this really in the patient’s best interest? A 2016 study says NO!

AATAC stands for: Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD

AATAC: Catheter Ablation vs. Amiodarone Antiarrhythmic Drug Therapy

In the powerful AATAC multicenter worldwide randomized trial, catheter ablation was compared to drug treatment with amiodarone (the most effective but also the most toxic of the antiarrhythmic drugs).

The 203 enrolled patients had persistent A-Fib and heart failure with an Ejection Fraction of less than 40%. Patients also all had either a dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator.

All patients in the AATAC study were given optimal medical therapy for congestive heart failure such as ACE inhibitors, etc.

Patients were randomized to receive either a catheter ablation or drug treatment with amiodarone.

Note: The AATAC study should be read in conjunction with the more significant CASTLE-AF study which found similar results.

Group 1: Catheter Ablation

The first group received a catheter ablation of the pulmonary veins (PVI) along with roof lines and extensive ablations on the left atrial posterior wall; if non-PV potentials were found, the superior vena cava was isolated. At their discretion, EPs could ablate complex fractionated electrograms and non-PV triggers.

A ‘re-do procedure’ could be performed during the 3-month blanking period.

Group 2: Amiodarone (AMIO) Drug Treatment

The Amiodarone (AMIO) group was given 400 mg twice a day for 2 weeks followed by 400 mg each day for the next 2 weeks, then they were given a maintenance dose of AMIO 200 mg/day for the balance of the 24 month study period.

Study Follow-up and Results

All patients were followed for a minimum of 24 months. Recurrence was measured by the implantable devices with device interrogation at 3, 6, 12, and 24 months follow-up. Key findings at the end of the trial period include:

Recurrence: 70% of patients in the ablation group were recurrence and A-Fib free (after an average of 1.4 procedures) vs. only 34% of the Amiodarone (AMIO) group.

PVI with/without posterior wall isolation: Higher success was reported in patients undergoing PVI with posterior wall isolation compared to PVI alone (79% vs. 8%).

Amiodarone therapy was found to be significantly more likely to fail.

Cardioversion: During the 3-month blanking period 51% of the Amiodarone (AMIO) group needed cardioversion vs. 3% of the ablation group.

The unplanned hospitalization rate was 31% in the ablation group vs. 57% in the AMIO group. This is a 45% relative risk reduction of hospitalization.

A significantly lower mortality was observed in the ablation group: 8% vs. AMIO 18%.

Summary: Catheter Ablation Superior to Amiodarone Drug Therapy

Heart failure and A-Fib are common cardiac conditions that often coexist.

The AATAC study, the first randomized study of heart failure patients with persistent A-Fib, found that catheter ablation is superior to amiodarone drug therapy in achieving freedom from A-Fib long-term.

In addition, treatment with catheter ablation improved mortality in these patients, increased exercise capacity and Quality of Life (QofL) along with reduced unplanned hospitalizations.

Acknowledging My Bias
I admit to being biased against amiodarone drug therapy due to personal experience and from what others have shared. (For example, see Karen Muccino’s A-Fib story.) I am horrified that anyone would be put on such a high initial dosage of amiodarone as in this study. I would never participate in such a study. But obviously all doctors don’t share my concerns.
If a less potent (and less dangerous) antiarrhythmic drug had been used, it’s probable the study results would have been even more favorable for the ablation group.

What This Means to A-Fib Patients

These patients were in persistent A-Fib along with heart failure. These are some of the most difficult patients to make A-Fib free.

The EPs and A-Fib centers in this study were some of the best in the world. That there was a 70% success rate and no recurrences after 2 years is a testimony to the advanced mapping and ablation skills of these EPs. It’s remarkable how far catheter ablation strategies have improved over the years.

On the downside, not all EPs are equal. The single procedure success rate varied greatly from 29% to 61%. (See Huge Growth in Number of EPs Doing Catheter Ablations, But All EPs Are Not Equal.)

Catheter Ablation Group: Improved Ejection Fractions

Among the 203 enrolled patients, it’s not surprising that there were 26 deaths during this study. These were very sick patients with congestive heart failure and Ejection Fraction below 40%. (An EF below 50% indicates a weakened heart muscle that is no longer pumping efficiently; an EF in the normal range is 50% to 75%.)

The good news is that for many in the catheter ablation group, their ejection fraction was significantly improved and they were no longer in heart failure.

Catheter Ablation Outperforms Antiarrhythmic Drugs

We now have 2 studies which demonstrate that compared to antiarrhythmic drug therapy, catheter ablation lowers death rate among A-Fib patients (with heart failure), improves QofL and lets patients live longer and healthier lives. Other major benefits of ablation include reduced unplanned hospitalizations and increased exercise capacity.

Take-Away for A-Fib Patients

I think we can draw conclusions from the AATAC and the CASTLE AF studies that also apply to A-Fib patients (not in heart failure).

Rather than a life on antiarrhythmic drug therapy, the AATAC and CASTLE AF studies encourage A-Fib patients to seek a catheter ablation (including a second “re-do ablation”, if necessary.)

Bottom-line: Hard research data shows that a catheter ablation is the better choice over drug therapy. An ablation can rid you of your A-Fib symptoms, make you feel better, and let you live a healthier and longer life.

Don’t just live with A-Fib. Seek your cure.

 

Resources for this Article
Di Biase, L., et al. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device. Results From the AATAC Multicenter Randomized Trial. Circulation. 2016;133:1637-1644. March 30, 2016. http://circ.ahajournals.org/content/133/17/1637 DOI  https://doi.org/10.1161/circulationaha.115.019406

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

Atrial Fibrillation Hospitalizations: Urban-Rural Differences in Mortality Rates

A new study suggests U.S. patients hospitalized for atrial fibrillation in rural areas may be more likely to die than those hospitalized in urban areas. 

In-hospital mortality was defined as death due to any cause during hospitalization.

Researchers examined nationwide information on 248,731 adults hospitalized for atrial fibrillation between 2012 and 2014. Mean age was 69 years; 78% white; 48% women. Of these, 218,946 (88%) were from urban hospitals and 29,785 (12%) were from rural hospitals.

Study Results: Urban vs. Rural

Patients admitted to rural hospitals had a 17% increased risk of death as compared with those admitted to urban hospitals. (Around 1.3 percent of atrial fibrillation patients died in rural hospitals, compared and 1 percent in urban facilities.) The study accounted for differences in patient characteristics including high blood pressure, diabetes, heart failure and kidney damage.

“…appropriate anticoagulation and…advanced options such as ablation, are lower in rural than urban settings.” Dr. Thomas Deering

According to lead study author Dr. Wesley O’Neal of Emory University School of Medicine: “Presumably, a higher risk of death in patients from rural regions was related to differences in practice patterns and access to specialists.” 

From a related editorial: “There is also some limited data suggesting that several atrial fibrillation outcomes, for example appropriate anticoagulation usage and appropriate referral for advanced procedural options such as ablation, are lower in rural than urban settings,” wrote Dr. Thomas Deering of Piedmont Heart Institute in Atlanta.

This study examination wasn’t a controlled experiment. Further research is needed to understand these findings.

What This Means to A-Fib Patients

Atrial Fibrillation is not a one-size fits all type of disease. Don’t choose your Atrial Fibrillation healthcare provider just because their office is nearby with local hospital privileges.

When seeking treatment for your Atrial Fibrillation, your first step is to see a heart rhythm specialist (a cardiac electrophysiologist) who specializes in the electrical function of the heart (and the best you can afford). You may need to travel, but it may be worth it to you for your peace of mind.

For more see Finding the Right Doctor for You and Your A-Fib and the A-Fib.com Directory of Doctors Treating A-Fib: Medical Centers and Practices.

Resources for this Article
O’Neal, W.T., et al. Urban-rural differences in mortality for atrial fibrillation hospitalizations in the United States. Heart Rhythm online December 10, 2017. DOI: http://dx.doi.org/10.1016/j.hrthm.2017.10.019

Rapaport, L. Atrial fibrillation more deadly in rural U.S. hospitals. Reuters Health, Jan. 2, 2018 https://www.reuters.com/article/us-health-afib-survival/atrial-fibrillation-more-deadly-in-rural-u-s-hospitals-idUSKBN1ER1NP

Patients With Atrial Fibrillation More Deadly In Rural U.S. Hospitals. PharmaInsider. January 3, 2018. http://pharmainsider.in/patients-atrial-fibrillation-deadly-rural-ushospitals/

Inherited A-Fib? Is it More Risky for Family Members?

Many A-Fib patients wonder if they will pass their Atrial Fibrillation on to their offspring. Called Familial A-Fib, your first-degree family members are at higher risk of developing A-Fib.

A-Fib accounts for one-third of all strokes in patients above the age of 65 and is also associated with an increased mortality.

Several studies have shown an association of genetic variants with A-Fib and indicated that Familial A-Fib increases the risk of developing A-Fib. Familial A-Fib may account for as many as 20% of A-Fib patients.

But there is good news. A Danish registry study found that a diagnosis of Familial A-Fib carries no greater risk of death and stroke than in the general Atrial Fibrillation population.

The Danish Familial A-Fib Study

The study from Danish nationwide registry data included 8,658 patients diagnosed with A-Fib from 1995 through 2012 with both parents known, matched 1:1 for familial A-Fib status as well as age, year of A-Fib diagnosis, and sex.

Familial A-Fib is more common in men than women and with median age of 50.

Study Findings: Compared with the entire A-Fib registry population, the familial A-Fib patients were less likely to be female (21% women versus the overall registry’s 47% women) and were younger at diagnosis (median age 50 vs 77).

An element to be taken into account is that families with long life expectancy, for any reason, may be at higher risk for familial A-Fib due to the longevity of relatives.

What Patients Need to Know

We have heard of many fathers and sons and sets of brothers with A-Fib as well as three-generations with A-Fib.

If you have Atrial Fibrillation, your first-degree family members (parents, siblings, offspring) may have Atrial Fibrillation and not know it. They may have ‘silent A-Fib’ with no or few apparent symptoms but with an increased risk of stroke.

Encourage family members to discuss Familial A-Fib with their doctors.

Be your family’s health advocate. Encourage family members to discuss Familial A-Fib with their doctors. A-Fib is usually easy to detect by taking your pulse and/or by an electrocardiogram (EKG or ECG). Early detection and treatment may avoid early health complications and prevent a cardiovascular event (i.e. A-Fib-related stroke).

For more about Familial A-Fib, see FAQs: Can I Prevent Familial A-Fib with Diet? Supplements?

A-Fib Personal Story on A-Fib.comDoes A-Fib Run in Your Family? 

Would you share your A-Fib story with our readers? We would love to hear from you. Our Personal Experiences stories are one of the most visited areas of A-Fib.com. Email me and tell me your story. (Or, read how to write and submit your A-Fib story.)

Resources for this article
Phend, C.  Afib in the family not riskier for outcomes death, thromboembolism rates similar to cases with no family history. Cardiology/MedPage Today. November 29, 2016. http://www.medpagetoday.com/cardiology/arrhythmias/61722

Kirchhof P, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS: the Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2016. URL: http://eurheartj.oxfordjournals.org/content/ehj/early/2016/08/26/eurheartj.ehw210.full.pdf. Accessed November 18, 2016.

Gundlund A, et al “Outcomes associated with familial versus nonfamilial atrial fibrillation: A matched nationwide cohort study” J Am Heart Assoc 2016; DOI: 10.1161/JAHA.116.003836, http://jaha.ahajournals.org/content/5/11/e003836

Fauchier L, et al “Prognosis in familial atrial fibrillation” J Am Heart Assoc. 2016; DOI: 10.1161/JAHA.116.004905

Jurkko R, et al. Characteristics of atrial fibrillation and comorbidities in familial atrial fibrillation. J Cardiovasc Electrophysiol.2013;24:768–774. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5210330/

2017 AF Symposium: Reports for Patients by Steve S. Ryan, PhD

AF Symposium 2017

My Summary Reports Written for A-Fib Patients

Steve Ryan in Orlando Jan 2017 for AF Symposium

Steve Ryan in Orlando Jan 12-14, 2017

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.

Archive Link: How to find my reports from all Atrial Fibrillation-related medical conferences

REPORT TITLE PRESENTER (S) DATE POSTED
15. Live Case of Ablation with FIRM Mapping System Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL March 16, 2017
14. Movin’ it: Protecting the Esophagus During Ablation – LIVE VIDEO Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt, Texas Cardiac Arrhythmia Institute, Austin, TX. March 11, 2017
13. LIVE VIDEO: Can Adding Fibrosis Improve Ablation Success? Drs. Kevin Heist and Nathan Van Houzen, Mass. General Hospital, Boston, MA March 8, 2017
12. LiVE VIDEO: Ablation Using Non-Contact Ultrasound Basket Catheter Dipole Density Mapping Drs. Peter Neuzil, Jan Petru and Jan Skoda, Na Homolce Hospital, Prague, The Czech Republic. Feb. 23, 2017
11. LIVE VIDEO: Ablation using CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon Drs. Peter Neuzil, Jan Petru and Jan Skoda, Na Homolce Hospital, Prague, The Czech Republic. Feb. 11, 2017
10, LIVE VIDEO! Two Procedures—Different Left Atrial Appendage (LAA) Occlusion Devices Drs. Claudio Tondo, Antonio Dello Russo, Gaetano Fassini, and Massimo Moltrasio, Milan, Italy Feb. 3, 2017
9. World-Wide Studies on Genetic A-Fib Dr. Patrick Ellinor of Mass. General Hospital, Boston MA Feb. 1, 2017
8. New Insights into the Effects of Obesity on Atrial Fibrillation Dr. Jose Jalife of the University of Michigan, Ann Arbor, MI Jan 28, 2017
7. A-Fib Increases Fibrosis by 5%-10% Per Year Dr. Nassir Marrouche of the University of Utah (CARMA), Salt Lake City, UT Jan 27, 2017
6. Hypercoagulability May Cause A-Fib, NOACs May Prevent It Dr. Ulrich Schotten of the University of Maastricht, Maastricht, The Netherlands Jan 27, 2017
5. Some Forms of Fibrosis May Be Reversible: Research with Overweight Sheep Dr. Stanley Nattel of the U. of Montreal, Montreal, Canada Jan 23, 2017
4. Links Between Inflammation, Oxidative Stress and A-Fib David Van Wagoner, PhD, the Cleveland Clinic, Cleveland, OH Jan 21, 2017
3. 3D Virtual Heart’ Predicts Location of Rotors Dr. Natalia Trayanova of Johns Hopkins University, Baltimore, MD Jan 21, 2017
2. 2017 European A-Fib Stroke Risk Guidelines Changes & No Gender Bias Dr. John Camm from St. George’s Medical Center, London, UK Jan 19, 2017
1. 2017 AF Symposium Overview by Steve S. Ryan, PhD – – – Jan 17,2017
Archive: Link to my 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: Thursday, June 1, 2017

Sleep Apnea: When Snoring Can Be Lethal

Obstructive Sleep Apnea (OSA) is so common that at least 43% of patients with Atrial Fibrillation also suffer with it. For that reason alone, you should be tested for sleep apnea.

Aside from causing or triggering A-Fib, untreated sleep apnea can cause many other serious health threats.

Got Sleep Apnea? Your Life-Threatening Risks

Researchers at the U. of Wisconsin examined 22-years of mortality data on the study’s participants and found the following:

infographic-sleep-apnea-stats-section-only-500-v-425-pix

The Wisconsin Sleep Cohort Study

Beginning in 1989, the U. of Wisconsin study used a random sample of 1,522 Wisconsin state employees. The participants underwent overnight sleep apnea studies and many other tests at four-year intervals. They were not selected because they had known sleep problems. (After the testing, researchers contacted participants with severe sleep apnea and explained the health risks.)

The study reveals the numerous life-altering and life-threatening health issues associated with sleep apnea.

Sleep Apnea: a condition in which one or more pauses in breathing occur while sleeping, pauses can last a few seconds to minutes and can occur 30 times or more an hour.

More EPs are Sending Patients for Sleep Studies

So many A-Fib patients also suffer from sleep apnea that many Electrophysiologists (EPs) routinely send their patients for a sleep apnea study. Some A-Fib centers have their own sleep study program. (The patient just walks down the hall to an A-Fib sleep study area.)

For some lucky patients, normal sinus rhythm (NSR) can be restored just by controlling their sleep apnea and getting a good night’s sleep.

Take Action: Sleep Apnea Can be Lethal

The Wisconsin Sleep Study findings demonstrate just how lethal sleep apnea can be. Sleep apnea isn’t a minor health problem, and it’s a condition you can do something about. (Just like A-Fib, you don’t have to just live with it).

If your significant other tells you that you pause breathing when you sleep or that you snore, do something about it! (Not everyone with sleep apnea snores, but snoring may indicate sleep apnea.)

Talk with your doctors about testing for sleep apnea. You may need an in-lab sleep study (or the newer option of a home sleep test).

Learn More About Sleep Studies

Read about in-lab and in-home sleep studies in our article, Sleep Apnea: Home Testing with WatchPAT Device and the Philips Respironics

On a Personal Note: My wife has sleep apnea (but not A-Fib). While sleeping, she would actually stop breathing for what seemed like a long time, then suddenly gasp for air. It was very scary! But now she uses a CPAP machine, sleeps soundly and wakes up rested.

Sleep apnea may run in families. Her brother has sleep apnea also.

Resources for this article
Dudley, David. World War ZZZ. AARP the Magazine, August/September 2016, p.51.

Young, Terry. New Wisconsin Study Documents Severity of Sleep Apnea Risk. UW Health 2008 Annual Report. http://www.uwhealth.org/about-uwhealth/annual-report/new-wisconsin-study-documents-severity-of-sleep-apnea-risk/15018

Nieto, Javier. Sleep Apnea Associated with Higher Mortality from Cancer. University of Wisconsin School of Medicine and Public Health. News and Events, Med.Wisc.edu, 05/21/2012. http://www.med.wisc.edu/news-events/sleep-apnea-associated-with-higher-mortality-from-cancer/37687

Clinical Study Findings: CryoBalloon Better Than RF Ablation?

We can now say that CryoBalloon ablation is better than RF, at least according to a secondary analysis of a recent clinical study.

In the FIRE AND ICE clinical trial by Dr. Karl-Heinz Kuck and his colleagues, 762 patients with symptomatic paroxysmal A-Fib were randomized into two groups, either RF catheter ablation or CryoBalloon ablation.

Results: Many findings were comparable. Both groups had similar results in terms of primary efficacy and safety endpoints. Furthermore, both groups had improvement in quality of life over 30 months of follow-up.

Where Results Diverged: Re-Hospitalization and Recurrence

While many of the outcomes were similar between the two groups, there were some significant differences. The CryoBalloon group had lower rates of re-hospitalization (32% with CryoBalloon versus 41.5% with RF catheter ablation). In addition, the CryoBalloon patients had fewer:

• Cardiovascular re-hospitalizations (23.8% vs 35.9%)
• Repeat ablations (11.8% vs 17.6%)
• Direct current cardioversions (3.2% vs 6.4%)

Karl-Heinz Kuck, MD portrait at A-Fib.com

KH Kuck, MD

According to lead researcher, Dr. Kuck:

“The secondary analysis (of the FIRE AND ICE study) favors CryoBalloon over (RF ablation), with important implications [for EPs] on daily clinical practice.”

Dr. Wilber Su of Banner-University Medical Center in Phoenix, who was not part of this FIRE AND ICE study, concluded:

Dr Wilber Su at A-Fib.com

Dr Wilber Su

“…for most operators, CryoBalloon may be a safer and more efficient approach… . In my practice, CryoBalloon has already become the preferred approach both from personal experience as well as patient demand.”

Added 8/7/17:  CryoBalloon Ablation is Cheaper Than RF
Saving were “primarily attributable to fewer repeat ablations and a reduction in cardiovascular rehospitalization with cryoballoon ablation,” investigators wrote in the Journal of the American Heart Association.

What Patients Need to Know

Which ablation procedure is better—RF or CryoBalloon? According to the FIRE AND ICE clinical trial, we can now say that CryoBalloon is better in terms of less re-hospitalizations, repeat ablations and recurrences within a 30 month period.

More important than the energy source used to perform the ablation, is the skill and experience of the operator (EP).

Don’t Avoid RF: In practical terms, the differences weren’t so great that you should avoid EPs who prefer to use RF.

Dr. Su points out that many electrophysiologists (EPs) may continue with RF ablation because being comfortable with their choice of technology is a critical factor.

Look for Skill and Experience: More important than the energy source used to perform the ablation, is the skill and experience of the operator (EP).

The Bottom Line: When researching an EP to do your ablation, look for the best, most experienced high volume operator you can find and afford, even if you have to travel.

Caveat About CryoBalloon Ablation

CryoBalloon catheter

CryoBalloon catheter

CryoBalloon ablation is much easier and faster to do than RF point-by-point ablation. Consequently, some operators are entering the field with little RF ablation experience on which to build or complement their Cryo skills.

Others are doing only “anatomical ablation”—only ablating the pulmonary vein openings and not looking for and ablating non-PV triggers. (Happily in many cases, this is often all that is needed, particularly in cases of recent onset or Paroxysmal A-Fib.)

For more critical information about choosing your EP for a Cryoballoon Ablation, read my posts:

• Huge Growth in Number of EPs Doing Catheter Ablations
• CryoBalloon Ablation: Alarming O.R. Reports (Part I)
• CryoBalloon Ablation: All EPS Are Not Equal (Part II)

Resources for this article
Lou, Nikole. Afib Ablation: Fewer Returns After ‘Ice’ Than ‘Fire’ MedPage Today/CRTonline.org June 14, 2016. http://www.medpagetoday.com/cardiology/pci/58529

Kuck K “The FIRE AND ICE trial secondary analyses: reintervention, rehospitalization, and quality-of-life outcomes” Cardiostim 2016. http://www.cardiostim.com/

Kuck KH, et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2016; 374(23): 2235-45.

Kuck KH, et al. Cryoballoon or radiofrequency ablation for symptomatic paroxysmal atrial fibrillation: reintervention, rehospitalization, and quality-of-life outcomes in the FIRE AND ICE trial. Eur Heart J (2016) First published online: 5 July 2016

Nu, Nicole. Cryoballoon ablation is cheaper than the radiofrequency alternative. MedPage Today/CRTonline.org, August 4, 2017

 

Considering a Mini-Maze? Don’t Destroy the Ganglionic Plexus

Many surgeons performing Mini-Maze or other Maze operations for A-Fib routinely ablate/destroy the Ganglionic Plexus (GP) areas on the outside of the heart which contain clusters of nerve cells.

But recent studies show this strategy is not only ineffective but causes a lot of complications.

AFACT stands for Atrial Fibrillation and Autonomic modulation via Thoracoscopic surgery

The AFACT Trial: Mini-Maze Surgeries for Paroxysmal or Persistent A-Fib

The 2016 randomized clinical trial from Amsterdam in The Netherlands included 240 participants who underwent mini-maze surgeries: totally thoracoscopic pulmonary vein isolation for paroxysmal A-Fib or isolation plus Dallas lesion set for persistent A-Fib.

Approximately half also received ganglionic plexus ablation in which four major ganglionic plexus were ablated as well as the ligament of Marshall in the ganglionic plexus group. Patients were followed for one year.

Results: Ablating GPs—No Clinical Benefit, More Complications

ganglionic-plexus-areas-420-x-400-pix-at-96-res

Areas outside of the heart with clusters of nerve cells.

The researchers found no clinical benefits associated with ganglion plexus ablation added to a thoracoscopic ablation strategy, and significantly more complications.

There were significantly more recurrences in the ganglionated plexus group (78.1%) than in the control group (51.4%). And what is worse, more than double the number of major adverse events occurred in the ganglionic plexus group such as major bleeding and sinus node dysfunction which required pacemaker implantation.

Presenting at 2016 Heart Rhythm Society scientific session, researcher Dr. Joris R de Groot stated that “ganglionic plexus ablation is associated with significantly more periprocedural major bleeding, sinus node dysfunction and pacemaker outcome, but not with improved rhythm outcome.”

He concluded that routine ganglionated plexus ablation offers “no clinical benefit” in this patient category, and “should not be performed.”

The 2016 AFACT trial may finally have determined that ablating GPs doesn’t work.

What Patients Need to Know

Surgery Not Recommended as First Choice Treatment for A-Fib: Current guidelines do not recommend surgery as a first choice or option for A-Fib. Surgery is generally more invasive, traumatic and risky than a simple catheter ablation procedure.

Routine ganglionated plexus ablation offers “no clinical benefit” and causes major permanent complications.

Most current surgical strategies have built in limitations. For example, if you have A-Flutter coming from the right atrium, current surgical techniques don’t access the right atrium or some other non-PV trigger sites. See Cox-Maze, Mini-Maze and Hybrid Surgeries. In such cases, one often needs a catheter ablation after the surgery.

Make Sure Your Surgeon Doesn’t Ablate Ganglionic Plexus Areas: If you have to have surgery for A-Fib, make sure your surgeon does not ablate the ganglionic plexus areas as part of his A-Fib surgery. Ablating the ganglionic plexus areas doesn’t improve ablation results and causes more major permanent complications. As Dr. de Groot unequivocally states, ganglionic plexus ablation “should not be performed.”

The Bottom Line if Having Mini-Maze Surgery

If you have to have surgery for A-Fib (versus a catheter ablation by an EP), make sure you ask the surgeon if they ablate the ganglionic plexus areas as part of your A-Fib surgery. (Don’t expect a surgeon to volunteer this info. You have to ask!)

If they say yes, hand them a copy of this post. Then find another surgeon.

Resources for this article
Routine ganglionic plexus ablation “should not be performed” in advanced atrial fibrillation patients. Cardiac Rhythm News, Issue 33, June 2016, p. 2. http://tinyurl.com/ganglionic-plexus-ablation

Driessen AH, et al. Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study. J Am Coll Cardiol. 2016;68(11):1155-1165. doi:10.1016/j.jacc.2016.06.036

Ganglionated Plexus Illustration: Heng, C. Atrial Fibrillation Mechanism and autonomic nervous ganglion ablation. http://www.365heart.com/show/83937.shtml

My 2nd Report: More from the 2016 Western AF Symposium

Second in a series By Steve S. Ryan, PhD

This is my second report on The Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Look for my first report with 9 brief summaries.

Introduction: 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.
This time I cover 6 brief summaries of technical presentations.
Skiing in Park City, UT

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

A New Ablation Parameters Concept for an Accurate Lesion Assessment During AF Ablation

Dr Moussa Mansour discussed the Biosense Webster’s Thermocool SmartTouch irrigated tip ablation catheter with force sensing technology and the St. Jude Medical’s TactiCath (Endosense) contact-force sensing ablation catheter. Each provides the operator with force and contact info which both lowers PV reconnection and the need for repeat ablations.

The newer contact force sensing catheters will also integrate not only force and contact info but also duration, power, catheter stability, and temperature to accurately predict lesion depth and quality. In one system, lesion tags will be automated. A (completed) lesion tag will only be displayed if the lesion meets pre-set criteria.

I’d like to put together a ‘Steve’s List’ of EPs using contact force sensing catheters, but I can’t get the information from the manufacturers (Biosense Webster and St. Jude Medical).
Contact force sensing catheters are a huge improvement in RF ablation. You should insist on an EP who uses contact force sensing catheters. Ask your EP office staff if they use contact force sensing catheters. If they don’t know what you are talking about, contact another EP.

Rotors in Human AF: Multicenter Experience

Dr. Gary Tomassoni has been using the FIRM 64 electrode basket mapping catheter to perform ablations. He uses FIRM-guided ablation in conjunction with PVI.

In his experience rotors are stable and are critical to success. He tailors his ablations to the location of the rotors which he uses as the anchors of the procedure. He starts with the right atrium, then moves to the left. In general, termination during the procedure works better than having to electrocardiovert the patient back to normal sinus rhythm.

Anticoagulation During AF Ablation: Multi-Center Experience

When using an open irrigated RF catheter along with warfarin, Dr. Natale’s group reported no stroke/transient ischemic attacks in 2,618 ablation patients even though they had a higher prevalence of nonparoxysmal A-Fib and higher CHADS2 scores. [In previous studies, patients with Persistent/Permanent A-Fib were more likely to develop strokes during RF ablation.] In a smaller study, uninterrupted rivaroxaban (Xarelto) during RF ablation reduced silent cerebral ischemia as detected by dMRI.

In a small study of apixaban (Eliquis) compared to warfarin, there were no strokes/TIAs and no silent cerebral ischemia in the apixaban group.

Dr. Natale concluded that uninterrupted Xarelto and Apixaban seem to provide the same protection as uninterrupted warfarin, though more data and studies need to be done to verify their safety.

He stressed that anticoagulation should be started before the transseptal puncture rather than after. [From the O.R. reports I’ve read, this doesn’t seem to be normal practice.]

Fiber Optical Balloon: Experience and Long-Term Outcome Data

Dr. Edward Gerstenfeld showed video and slides of the CardioFocus Laser Balloon Catheter (not yet approved for use in the US). In addition to the operator being able to see directly where he is ablating through optical fiber, the balloon is compliant and can adapt to the individual contours of the pulmonary vein. 99% of PVs were isolated with the balloon alone.

Results are similar after 1 year to irrigated RF ablation. Over 7,000 ablations using the Laser Fiber Optic Balloon catheter have already been performed in Europe. See my article on Laser Balloon Catheter.

Long Term Follow Up on Patients with Failed Ablation of AF

Dr. David Callans pointed out that patients with a successful A-Fib ablation do better than A-Fib patients without ablation in terms of three-year mortality and stroke. A study of 3,355 patients at 3 centers over four years who had a successful A-Fib ablation, found those patients had very little stroke risk even compared to patients still taking anticoagulants.

Of patients not taking anticoagulants who had a CHADS2 risk score of greater >2, none had an ischemic stroke (A-Fib related stroke). Whereas in the group still taking anticoagulants, 2% had a hemorrhagic stroke vs 0.04% of those not taking anticoagulants.

But what happens to patients with a failed ablation? Dr. Callans asked, are their A-Fib symptoms worse? Are they at increased risk of stroke despite anticoagulation? Are they more likely to die (increased risk of mortality)?

In a 3-year follow-up study of non-paroxysmal A-Fib ablation at the Un. of Pennsylvania, the answers to these questions were not good. In the group that remained in persistent A-Fib (n=62), 20 had at least one repeat ablation. 96% remained on oral anticoagulants [I wonder: why weren’t 100% on anticoagulants?]. But A-Fib symptoms were generally manageable with rate control drugs. During the 3-year follow-up:

• Four had an AV Node Ablation and Pacemaker procedure (usually a measure of last resort; see my article, Ablation or Modification of the Atrioventricular (AV) Node and Implanting a Pacemaker)
• There were three deaths
• There were two strokes and one TIA (Transient Ischemic Attack, i.e., a temporary “mini-stroke”)
• There were two episodes of serious bleeding

Because of the small numbers, it’s hard to draw significant conclusions. But mortality was significantly higher in the group that remained in persistent A-Fib. This increased risk of mortality may be tied to increased comorbidities (i.e., obesity, diabetes, hypertension, sleep apnea, etc.) in this group.

Reference for this brief
Themistoclakis, S. et al. The Risk of Thromboembolism and Need for Oral Anticoagulation After Successful Atrial Fibrillation Ablation. J. Am. Coll. Cardiol. 2010;55:735-743. http://content.onlinejacc.org/article.aspx?articleid=1140481&issueno=8.  doi:10.1016/j.jacc.2009.11.039

Monitoring AF After Treatment: How Long and How?

Common practice today is to wait to assess the efficacy of catheter ablation for at least three months following catheter ablation—the “blanking period.”

But Dr. Suneet Mittal discussed the importance of monitoring AF burden (the amount of time the patient spends in A-Fib) during the blanking period. Dr. Mittal found that patients with more AF Burden during the blanking period were more likely to have recurrence. 100% of the patients studied with a >15% AF Burden during the blanking period experienced recurrence.

He also found that Intermittent Rhythm Monitoring (IRM) such as by 24-hour Holter monitors is significantly inferior to Continuous Monitoring (CM) by devices such as the Reveal LINQ Insertable monitor which a patient can have inserted under their skin for up to three years. Typical short-term monitoring (IRM) after an ablation may miss a great deal of A-Fib burden and chance of recurrence. But it may not be realistically possible to implant a CM device in all A-Fib patients.

Dr. Mittal recommended that current guidelines be changed to continue monitoring after an ablation. He added that after an ablation patients should be encouraged to take their pulse to monitor for irregularity and asymptomatic A-Fib episodes.

Reference for this brief
Charitos, EI et al. A Comprehensive Evaluation of Rhythm Monitoring Strategies for the Detection of Atrial Fibrillation Recurrence. Circulation. 2012; 126:806-814. http://circ.ahajournals.org/content/126/7/806.full. doi: 10.1161/circulationaha.112.098079.

Report 2: Wrap Up Highlights

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 the EP with force and contact info, the new catheters will integrate duration, power, catheter stability and temperature to improve ablation quality.

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.

Dr. Callans pointed out that patients with a successful A-Fib ablation had very little stroke risk. Where as 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.

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). The challenge is finding a practical, cost-effective way to offer continuous monitoring to everyone over age 65. This is a major public health issue.

If you are on the NOACs Xarelto and Eliquis, Dr. Natale’s data is encouraging news. When having an ablation, you don’t have to switch back to warfarin beforehand. (They couldn’t say that about Pradaxa, see Pradaxa Danger Ablatlion—Switch to Warfarin.)

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.) Could we be close to dropping ‘stroke’ as a possible complication during an ablation?

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

Doctors mentioned in this report along with their affiliations
Dr Moussa Mansour, Massachusetts General Hospital
Dr. Gary Tomassoni, Baptist Health, Lexington in Kentucky
Dr. Andrea Natale,  Texas Cardiac Arrhythmia
Dr. Edward Gerstenfeld, UCSF Medical Center
Dr. David Callans, University of Pennsylvania
Dr. Suneet Mittal, Arrhythmia Associates of NY & NJ

Return to 2016 Western AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, April 14, 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.

2016 Western Atrial Fibrillation Symposium: Reports Written for Patients

2016 Western AF Symposium square logo BRIGHTER 2Park City, Utah! Snow. Snow! Snow!! What a wonderful winter venue for the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016.

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).

Besides sharing technical research presentations, the Western AF Symposium also included ‘softer topics’ for doctors like using with social media and working with broadcasters to communicate with patients. In all, there were 53 scheduled presentations of 15 minutes each.

The first two reports are a condensed format with multiple topics per report. Email me and let me know if you enjoy this format.

Report  Topic  Publication date
3 Stroke: Is It A-Fib or Something Else?
Dr. Jennifer Majersik, The Stroke Center of the Un. of Utah  
 May 20, 2016
2 Summary Report 2 (covers 6 presentations)   April, 4, 2016
1 Summary Report 1 (covers 9 presentations)  March 21, 2016
More reports to come.

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.

My 1st Report from the 2016 Western AF Symposium

By Steve S. Ryan, PhD, March 2016

Utah! What a wonderful winter venue. The Park City Marriott was the site of the Ninth Annual Western Atrial Fibrillation Symposium held  February 26-27, 2016.

After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant info was provided (sometimes by the same presenters).

There were 53 scheduled presentations of 15 minutes each. A question & answer session followed every four presentations with the previous 4 speakers and moderators talking with the audience.

Skiing in Park City, UT

Park City, UT

In this first report, I’ve summarize 9 presentations and a Q & A session.

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.

Today’s guidelines recognize that it’s usually better for A-Fib patients to get back into normal sinus rhythm (NSR). But today’s antiarrhythmic drugs often don’t work. Once they fail, catheter ablation is superior. Today’s guidelines also recognize that it’s OK to do an ablation first, i.e., ablation can be a first choice. This means A-Fib patients don’t have to try and fail antiarrhythmic drugs before having an ablation.

Structural and Electrical Remodeling: From an Experimental Perspective

Hypercoagulability: a potentially dangerous condition in which blood coagulates excessively, even within the blood vessels.

Dr. Uli Schotten, gave perhaps the most innovative, breaking-new-ground presentation. He discussed how the very dangerous condition, hypercoagulability, is linked to fibrosis and A-Fib.

He discussed how NOACs (Novel Oral Anticoagulants) decrease the risk of an A-Fib stroke. In addition, they may also be a potential ‘Upstream Therapy’ to prevent the development of A-Fib by reducing hypercoagulability and the development of fibrosis.

[Think of ‘Upstream Therapy’ like living in a houseboat on a river. Anything upstream will ultimately affect you as it flows downstream. Furthermore, preventative steps ‘upstream’ can keep you from harm or improve your life ‘downstream’. See Upstream Therapy” Concept: Alternative Therapies for A-Fib?]

ASSERT Study: Are ‘Undetermined Source’ Strokes Actually from Silent A-Fib?

Dr. John P. DiMarco discussed stroke without any obvious causes (formerly called Cryptogenic, but now called “ESUS” [Embolic Stroke of Undetermined Source]). ESUS strokes accounts for 20%-30% of all strokes. He noted that, within two years of having an ESUS stroke, patients often develop A-Fib.

In addition, he discussed the ASSERT (Atrial Fibrillation Reduction Atrial Pacing Trial) study which studied 65-year-olds or older with hypertension. The study revealed that those with a pacemaker or ICD who experience a six minute or longer attack of ‘subclinical atrial fibrillation’ (asymptomatic or silent A-Fib), was at higher risk of stroke. Many ESUS strokes thought to be of “undetermined source”, may actually come from silent A-Fib.

Sleep Apnea and A-Fib

Dr. Larry Chinitz pointed out that sleep apnea, along with causing a host of other problems, expands the left atrium and causes fibrosis. CPAP (Continuous Positive Airway Pressure) breathing machines virtually eliminate sleep apnea and also reduce recurrence after an ablation.

The problem is 50% of patients don’t use theirs. These patients might be receptive to an alternative—a custom oral dental appliance that’s made by a qualified dentist in dental sleep medicine.

[These dental appliances prevent the airway from collapsing by supporting the jaw in a forward position. Caution: This may lead to misalignment of your jaw affecting your bite and causing headaches.]

In his practice, Dr. Chinitz requires that every A-Fib patient be screened for sleep apnea.

Proposed A-Fib Ablation Registry

During the question and answer session (following the above presentations), there was a lot of discussion about the proposed A-Fib ablation registry by the American College of Cardiology. The general consensus was: the ACC registry will be very burdensome and costly with 250 data points to be collected including a 20-question patient quality of life questionnaire; simpler, more focused, less burdensome registries are needed; they should be produced by electrophysiologists (EPs) instead.

You may recognize some of the speakers from my reports on the 2016 AF Symposium held in January.

How Many Times Can We Re-Do A-Fib Ablations?

Dr. Hugh Calkins stated that there is no limit to how many re-do ablation can be done. The risks for a second or third ablation compared to a first are similar. But there will be more RF scarring of the septum with each transseptal puncture. Dr. Calkins emphasized that re-do ablations should be done only after the blanking period (three months after the ablation). When re-doing an ablation, he always re-ablates (isolates) the PVs (Pulmonary Vein Openings).

Promoting AF Awareness Through The Media

Dr. John Campbell of Fox News explained how EPs should be media advocates. They should contact their local TV, radio and other media outlets and offer their services, particularly on Heart Health events or when news breaks about heart related topics.

He showed studies of how people can be greatly influenced by doctors on TV. In one study, for example, when doctors explained why to quit smoking, 1/3 of people hearing this advice did try to stop smoking. He also gave specific presentation advice and showed illustrative interview clips.

[See also my article: TV Doctors’ Talk Shows: Can You Trust Their Recommendations?]

Lesion Imaging Using MRI: Heating To Cooling

Utah is home to The CARMA Center at the U. of Utah, a leader in MRI research and A-Fib. 

Dr. Eugene Kholmovski showed how the unique and perhaps most important contribution MRI may make to A-Fib is to examine and accurately determine the integrity of A-Fib lesions. He showed many imaging slides and explained how a good lesion should look, and that it works for both lesions made with RF (heating) and Cryo (freezing) energy. When checking on the integrity of lesions, he cautioned to wait at least one week after ablation. Otherwise, edema (swelling caused by ablation) may prevent the MRI from clearly examining the lesion.

Gender Influence in Patients with Arrhythmia

Dr. Nazem Akoum reported he found few differences between male and female patients with A-Fib with two major exceptions. Women have more fibrosis than men, and women with fibrosis have a much higher risk of stroke.

How Social Media are Changing Managing Patients and Physician Approach

Dr. John Mandrola (‘Dr. John M’) gave several examples of how a researcher/EP can take advantage of social media channels like blogs, Twitter and Facebook to communicate with patients.

He gave the example of a researcher who writes a scholarly article “Warfarin vs the Novel Oral Anticoagulants.” This same article can be re-written for patients with a more patient-friendly title, such as, “How to Avoid a Stroke” and removing all the difficult-to-understand medical terms, then publish it as a blog post. In addition, the researcher can create a personal tweet: “I may have saved someone from having a stroke today. He started taking (name of anticoagulant).”

This shows how the same content can be re-written to reach patients through different media channels.

[Dr Mandrola is one of the more proficient EPs I know using social media and has a huge following. At DrJohnM.org, he blogs about A-Fib, heart rhythm and general cardiac matters, and the world of cycling.]

First Report: The Wrap Up

This is just my first report. There’s more coming in the following weeks.

I was surprised at how much new, relevant info was provided since the January international AF Symposium in Orlando. Besides technical research presentations, the Western AF Symposium also included ‘softer topics’ like using with social media and working with broadcasters to communicate with patients.

Return to 2016 Western AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, April 14, 2016

Doctors mentioned in this report with their affilications
Below is a list of the presenters in this article:

Dr. Eric Prystowsky, St. Vincent Medical Group, Indianapolis, IN
Dr. Uli Schotten, Maastricht University, The Netherlands
Dr. John P. DiMarco, UVA Specialty Care, Fishersville, VA
Dr. Larry Chinitz, NYU Langone Medical Center, New York, NY
Dr. Hugh Calkins, Johns Hopkins Hospital, Baltimore, MD
Dr. John Campbell, Fox News
Dr. Eugene Kholmovski, Univ. of Utah, Salt Lake City, UT
Dr. Nazem Akoum, Univ. of Utah, Salt Lake City, UT
Dr. John Mandrola, Louisville Cardiology Group, Louisville, KY

Staying in A-Fib Reduces Brain Volume & Cognitive Function

A study of brain atrophy from Iceland found that A-Fib in the elderly caused accelerated loses of brain volume and cognitive function.

Study of brain volume and cognitive function in A-Fib patients

Study of brain volume and cognitive function in A-Fib patients

This is yet another study driving a stake into the heart of the notion that you can just leave patients in A-Fib with anticoagulants and rate control drugs, and they will live happily ever after.

“It’s better for the brain to remain in sinus rhythm than to pursue rate control of A-Fib” stated Dr. David O. Arnar, speaking of the AGES-Reykjavik Study results at the 2015 Euro Society of Cardiology Annual Congress.

The AGES-Reykjavik Study

Over two thousand elderly subjects without dementia (mean age 67 years old) were tested and followed for over 5 years. Participants had brain MRIs and structured cognitive function testing during the duration of the study.

The 2,472 elderly patients fell into three groups: those who remained A-Fib-free throughout the study, those with confirmed A-Fib at the start (121), and those who developed new-onset A-Fib (132) by the end of the study.

AGES Findings: Brain Matter

At the end of the follow-up period, all participants had a reduction in brain grey matter. The amount of reduction varied significantly by group:

• A-Fib-free: 1.8% decrease
• Ongoing A-Fib: 2.79% decrease
• New-onset A-Fib: 6.5% decrease

… Continue reading this report…->

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
Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659-666.
Footnote Citations    (↵ 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
King, JB et al. Association of atrial fibrosis with major adverse cardiac events in patients with non-valvular atrial fibrillation: abstract 16572. Circulation. 2015; 132:A16572. http://circ.ahajournals.org/content/132/Suppl_3/A16572

Beiging, Erik et al. LA shape is a strong independent predictor of outcome after AF ablation. 2015 Heart Rhythm Society.

Suksaranjit P et al. Incidental LV LGE on CMR imaging in atrial fibrillation predicts recurrence after ablation therapy. JACC Cardiovascular Imaging. 2015 Jul;8(7):793-800. http://www.ncbi.nlm.nih.gov/pubmed/26093929. doi: 10.1016/j.jcmg.2015.03.008. Epub Jun 17, 2015.

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

A Watchman and Ablation Combo? Everything You Never Thought to Ask

by Steve S. Ryan, PhD

The Watchman device closes off the Left Atrial Appendage (LAA), the source of most clots and A-Fib strokes.

The Watchman has been available in other countries since 2009, but only since 2015 in the US.

Research tells us that the Watchman device is not only as good as but is actually better for A-Fib patients than being on the blood thinner warfarin.  (See my post: Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin)

Answers From Australia

A five-year study in Australia by Dr. Karen Phillips and her colleague, Dr. TW Walker, gives us ‘real world’ data and insights. Specifically, she studied combining the Watchman device with a catheter ablation for treating Atrial Fibrillation patients.

I’ve corresponded with Dr. Karen Phillips to help me answer your questions about the Watchman device.

“Can the Watchman be installed at the same time as my ablation?“

Yes.  Dr. Karen Phillips and several Electrophysiologists (EPs) in Europe have been doing this for over five years with no complications. She hasn’t seen any downside to doing the two procedures together. There’s very little, if any, experience in the US of combining a PVI with a Watchman device (US approved in 2015).

Should the Watchman be installed at the same time as my ablation?“

First answer: should the LAA be closed off? (Surgeons, unlike EPs, routinely remove the LAA in A-Fib surgery.) But the LAA isn’t a useless appendage and it has several functions. Younger people, especially the athletic, might be compromised by having their LAA closed off. (See LAA Important for Heart health.) There are many arguments for not routinely closing off the LAA in everyone. … Continue reading this report…->

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 began by 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
Oakes RS et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation, 2009 April 7;119(13): 1758-67. http://www.ncbi.nlm.nih.gov/pubmed/19307477 doi: 10.1161/circulationaha.108.811877. Epub 2009 Mar 23.

DECAAF Trial: Delayed-Enhancement MRI (DE-MRI) Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01150214

O’Riordan, M. DECAAF: Targeting MRI-Identified Fibrosis During Ablation Improves Outcomes. Heartwire (Conference News).  Sept. 01, 2013. http://www.medscape.com/viewarticle/810308

Hansen BJ et al. Atrial fibrillation driven by micro-anatomic intramural re-entry revealed by simultaneous sub-epicardial and sub-endocardial optical mapping in explanted human hearts. Eur Heart J 2015 Sept. 14;36(35):2390-401. http://www.ncbi.nlm.nih.gov/pubmed/26059724. doi: 10.1093/eurheartj/ehv233. Epub 2015 Jun 8

McDowell, KS. Virtual Electrophysiological Study of Atrial Fibrillation in Fibrotic Remodeling. PLOS One, February 18, 2015. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117110. DOI: 10.1371/journal.pone.0117110

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Friday, August 4, 2017

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?

Return to 2016 AF Symposium Reports reby Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Monday, February 15, 2016

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