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


Significant Research and Scientific Studies

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.”

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

 

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

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

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

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

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 2Utah! 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

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…->

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

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 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

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 15, 2016

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

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

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.

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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.

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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

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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.)

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