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


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

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

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

Jill and Steve Douglas, East Troy, WI 

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

Faye Spencer, Boise, ID, April 2017

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

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


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


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

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

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

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

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

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

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

Ira David Levin, heart patient, 
Rome, Italy

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

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


Treatments

Know All Your Treatment Options Before Making Important Decisions

Treatments for Atrial Fibrillation include both short-term and long-term approaches aimed at controlling symptoms or totally eliminating the abnormal heart rhythm associated with A-Fib. To learn about all your treatment options, go to our page, Treatments for Atrial Fibrillation.

Which of the A-Fib Treatment Options is Best for You?

Choosing from the Atrial Fibrillation treatment options is a decision only you and your doctor can make. But depending on your symptoms and type of A-Fib you have, we offer some guidelines which may help you. We list A-Fib conditions as described by those with A-Fib. Select one (or more) that best describes your A-Fib and read your possible options. Go to Which of the A-Fib Treatment Options is Best for Me?

Leaving the Patient in A-Fib—No! No! No!

Remember: ‘A-Fib begets A-Fib.’ The longer you have A-Fib, the greater the risk of your A-Fib episodes becoming more frequent and longer, often leading to continuous (Chronic) A-Fib. (However, some people never progress to more serious A-Fib stages.) To learn more, read my editorial, Leaving the Patient in A-Fib—No! No! No!

Don’t let your doctor leave you in A-Fib. 
Educate yourself. Learn all your treatment options.

Anticoagulants, Dementia and Atrial Fibrillation

The prevalence of dementia and atrial fibrillation (A-Fib) are both on the rise with the aging population and increasing burden of vascular risk factors.

The association between A-Fib and dementia is well documented. To describe that relationship, researchers use the term “strongly associated” rather than explicitly state that A-Fib causes or leads to dementia. That’s as far as they can go, because there might be other factors at play.

Patients with A-Fib lose 15%-30% of their heart’s ability to pump blood to their brain, and to the rest of their body.

A-Fib Linked with Dementia

As patients, we use more direct language. All things being equal, we say A-Fib leads to and/or causes dementia. It makes intuitive sense, doesn’t it? Patients with A-Fib lose 15%-30% of their heart’s ability to pump blood to their brain, and to the rest of their body. (See: Increased Dementia Risk Caused by A-Fib: 20 Year Study Findings)

Research confirms that older adults with dementia had significantly reduced blood flow into the brain compared with older adults with normal brain function or young adults.

Research Reveals: Anticoagulants Reduce Risk of Dementia

Swedish study investigated the effect of anticoagulation on the development of dementia among A-Fib patients. Research data was collected on patients diagnosed with and treated for A-Fib in Sweden between 2006-2014. This included 444,106 patients, and over 1.5 million patient-years.

The retrospective registry study compared the incidence of dementia developed in A-Fib patients with and without ongoing anticoagulation with warfarin or direct oral anticoagulation (DOAC) (i.e., dabigatran, rivaroxaban, apixaban and edoxaban).

This study of A-Fib patients found that anticoagulant treatment was associated with a 29% reduced risk of dementia. There was no difference in dementia risk between patients treated with warfarin and those treated with direct oral anticoagulants. 

It’s encouraging to know that, if you have A-Fib and must take anticoagulants, they may reduce dementia to a limited degree.

The authors concluded that the risk of dementia is higher among A-Fib patients not treated with anticoagulation.

In fact, absence of anticoagulation treatment was among the strongest predictors for dementia along with age, Parkinson’s Disease, and alcohol abuse.

Anticoagulants May Reduce Micro-Clots

This study did not tell us how anticoagulation achieves this effect.

Some speculate that anticoagulants, while preventing macro-clots (strokes), also prevent or reduce micro-clots and smaller ischemic events which damage the brain over time.

Another Reason to Not Live with A-Fib

This study also raises another reason not to live in A-Fib if at all possible. Unlike macro-clots which cause strokes and which can kill or severely disable, A-Fib tends to produce micro-clots (smaller ischemic events or silent mini-strokes). The effect of micro-clots may not even be noticeable but, nonetheless, damages our brains over time.

Resources for this Article

 

From My Mailbox: Catheter Ablation Complication Rate: Compared to What?

Frequently I get emails asking about the complication rate of catheter ablation.

I like the suggestion made by Dr. David Keane of St. Vincent’s University Hospital, Dublin Ireland. Complications from A-Fib ablation should be viewed in perspective, that is, compared to the alternative of a lifetime on antiarrhythmic drugs (AADs).

The following is based on his presentation from the 2014 Boston AF Symposium.

Meta-Analysis: RF Catheter Ablation vs. Antiarrhythmic Drugs

In what may be the first systematic literature review and meta-analysis of clinical studies of Radiofrequency Ablation (RFA) vs. Antiarrhythmic Drugs (AADs), the reviewers looked at studies from 1990 to 2007. [Note: RFA wasn’t in use until the mid-1990s.] Included were sixty-three RFA studies and 34 AAD studies.

RF Ablation: From 1990-2007, the single procedure success rate for Radiofrequency Ablation (RFA) without need of post-op Antiarrhythmic Drug (AAD) therapy was 57% [today’s success rates are in the 70%–85% range], multiple procedure success rates without post-op AADs were 71% [today’s success rates are closer to 90%], and the multiple procedure success rate with post-op AADs was 77%.

AAD Therapy: The success rate for AAD therapy alone was 52%.

Note: The meta-analysis included five AADs: amiodarone, dofetilide, sotalol, flecainide, and propafenone. Amiodarone was the most effective. [Amiodarone is the most toxic and dangerous of the five AADs and is usually prescribed only for short periods of time and under close supervision for bad side effects.]

Adverse Event: side effect or any undesirable experience associated with the use of a medical product in a patient. In the US, adverse events are reported to the FDA.

Side Effects Cause Patients to Stop Taking AADs: Because of adverse events (side effects), 10.4% of patients discontinued taking their AADs, 13.5% discontinued AADs because of treatment failure, and 4.2% just didn’t take the AADs.

The overall discontinuation rate of AADs was almost 30%.

Findings: Efficiency and Complications Rates

Based on the meta-analysis, reviewers found Radiofrequency Ablation (RFA) had a higher efficiency rate and a lower rate of complications than AAD Therapy.

Findings: Adverse Events Ablation vs AAD

As a point of reference, the complication rate of the common appendectomy is 18%.

This meta-analysis found adverse events for catheter ablation was 5% vs 30% for AAD studies.

More about AAD Therapy adverse events: The overall death rate for AAD therapy was 2.8% (i.e., sudden death 0.6%, treatment-related death 0.5%, non treatment-related death 1.3%). Other adverse events from AAD therapy were:

•  CV (cardiovascular) Events 3.7%
•  Bradycardia 1.9%
•  GI (Gastrointestinal problems) 6.5%
•  Neuropathy 5.0%
•  Thyroid Dysfunction 3.3%
•  Torsades 0.7%
•  Q-T prolongation 0.2%

Conclusions from Meta-Analysis

Most adverse events associated with antiarrhythmic drugs (AADs) are life altering and permanent. (For example, bradycardia requires a pacemaker.)

Whereas complications from catheter ablation are generally short term and not permanent. (For example, when tamponade is repaired, the heart usually returns to normal.)

While this meta-analysis covered 1990-2007, based on subsequent research the trends are continuing. In general, it appears it’s safer to have an ablation than to not have one while living a life-time on AAD therapy.

D. Keane MD

The Full Report: For the full summary of Dr. Keane’s 2014 Symposium presentation, see: Catheter Ablation Complications: In-depth Review and Comparison with Antiarrhythmic Drug Therapy.

What this Means to Patients

If you are age 70 or 80, antiarrhythmic drugs might be a realistic option.

But if you are younger, it’s inconceivable that you would spend the rest of your life taking AADs. In addition to not working well or losing their effectiveness over time, they can have bad, cumulative side effects as described above.

Today’s ‘Guidelines for the Management of Patients with Atrial Fibrillation’ reflect this fact and allow you to select a catheter ablation without having to spend time trying various antiarrhythmic drugs (while your A-Fib may be getting worse).

In general, research shows it’s safer to have an ablation than to not have one (and live a lifetime on AA drug therapy).

Resources for this Article

Story Update: Ashley Mogg, a 23-Year Old Jamaican, Now A-Fib Free!

I’ve seldom been so happy to write about an A-Fib success story (actually an update)! A story that had such a miserable beginning.

A-Fib at 17 and Started Losing Sight!

Eighteen months ago, I wrote a story about 21-year-old Ashley Mogg from Jamaica. Her A-Fib was horrible. Her first A-Fib attack came at age 17 when she had just stopped playing field hockey. Ashley wrote:

Ashley Mogg from Jamaica

“I was feeling extremely unfit. My heart rate sped up and my chest got tight. My throat felt like it was closing, and I was starving for a breath. Then the most frightening thing happened―I started losing my sight! Pitch black was all I saw. I could hear my friend talking to me through it. It was so scary for me.”

Her doctor told her losing sight was a symptom of pre-faint or pre-syncope. Her stress test showed a heart rate that at times went up to 270 bpm.

Clinical Depression Sets In

To make matters worse, her cousin died suddenly. Then Ashley had to have an appendectomy which revealed a low grade Neuroendocrine tumor (cancer). Coupled with her dreadful A-Fib symptoms, she became extremely depressed and anxious (clinical depression is all too common in new A-Fib patients). She also suffered weight loss and became very thin.

No A-Fib Centers in Jamaica

Unfortunately, when I researched resources for her I couldn’t find any A-Fib centers or Electrophysiologists in Jamaica. It was heart breaking that such a young woman had such a debilitating case of A-Fib, and I couldn’t find anyone near her to take care of her.

November 2016: Asking for Funding and Help for Ashley

What I did was publish her story on A-Fib.com and ask for donations to pay for her to see an EP in the U.S. (Read Jamaican Woman, 21, Living in A-Fib with Meager Treatment)

Dr. Natale confirmed that there was no EP lab in Jamaica and would try to find money from the A-Fib industry to help Ashley.

In addition, I sent Ashley’s story to Dr. Andrea Natale, a master EP with a world-wide reputation. A colleague of his, Dr. Francesco Santoni, emailed me that he tries to help arrhythmia patients in Jamaica through the Rotary Club and another foundation. Travis Smith, President of the Rotary Club of Downtown Kingston, Jamaica championed Ashley’s cause.

Dr. Natale suggested we work with Dr. Lisa Hurlock in Kingston, Jamaica at the University of the West Indies who could follow her arrhythmia. She met with Ashley and her mother, Loretta. Dr. Natale confirmed that there was no EP lab in Jamaica. He said he would try to find money from the A-Fib industry to help Ashley.

Dr. Natale’s Heroic Efforts to Help Ashley―Biosense Webster Donation

Dr Andrea Natale

Dr Andrea Natale

Dr. Natale obtained a donation from Biosense Webster (Johnson & Johnson) to cover travel expenses for Ashley and her mother to St. David’s Medical Center, Austin, TX including lodging, food and transportation. He also arranged for St. David’s to waive all fees for Ashley’s catheter ablation. The Texas Cardiac Arrhythmia Foundation accepted donations to help Ashley. Barbara Thomas and Amy Dixon coordinated everything at St. David’s.

(I probably don’t have all the names of everyone involved in helping Ashley. Please email me if I haven’t mentioned you or someone else who helped.)

Ashley, mom Loretta and hospital staff

July 2017: Ashley Has Her Ablation & is A-Fib Free!

On July 19, 2017, Ashley had her ablation. She is now A-Fib free. It was performed by Dr. Natale and his team at St. David’s Medical Center, Austin, TX. Since then, she has written that she is doing fine and has started college in Jamaica (she wants to go to medical school).

In an excerpt from her personal story (written before her ablation became a reality), Ashley shared these lessons learned:

“Educate Yourself―Find the Best Doctors Available. If you live in a country like myself where there are very few Electrophysiologists or heart rhythm specialists, find a reliable cardiologist as well as a general doctor who know your history. Do maximum research on your own and with your doctor and health care professionals. Stay informed.
…Stay positive…You are NOT ALONE!”

Remarkable for a 21-year old who has had a rapid beating heart since childhood.

March 2018 Update: Email from Ashley’s Mother

Loretta Mogg, Ashley’s mother recently wrote me:

Ashley and her mom, Loretta

“I am Loretta Mogg, the mother of Ashley Mogg. I want to express a heartfelt thanks to you for posting my daughter’s story and seeking help for her.
Just a little update. After nearly a year since her ablation, she is back in University and doing well. She is still determined to become a doctor.
Thank you for allowing God to use your own experience to change the life of another. Blessings to you and your family.”

Thanks to All, Especially to Dr. Natale

It’s impossible to adequately thank everyone, especially Dr. Natale, who helped Ashley in her incredibly difficult A-Fib journey.

I don’t know if we’ll ever understand how a young 17-year-old woman could develop such awful A-Fib symptoms. (Perhaps it related to her cancerous appendectomy.)

Faith and a Purposeful Life

Kudos to Ashley for not giving up with all she went through! She’s an incredible young woman. She had to grow up fast. She became a woman of faith with a purposeful life. In her own words, “It takes prayers and positive thinking to keep living with peace of mind.”

Be Inspired: You, too, Can Help Others With A-Fib

One-to-One, our A-Fib Support Volunteers are just an email away at A-Fib.comOne way to live a life of faith and purpose is to help others suffering with Atrial Fibrillation. Join our Prayer and Positive Thoughts group or our A-Fib Support Volunteers group.

Offering hope: Having someone you can turn to for advice, emotional support, and a sense of hope that you can be cured, may bring A-Fib patients (and their families) peace of mind.

We are blessed to have many generous people who have volunteered to help others get through their A-Fib ordeal (not all are ‘cured’). To learn more and how you can join the effort, see my article: ‘Want to Become a A-Fib Support Volunteer?

New FAQ: Which antibiotics are less liable to cause an A-Fib attack?

A question from Ellen McCall lead me to turn to our world-wide A-Fib.com Advisory Board for an answer. Several EPs shared their opinions, research data and insights from their practices in answer to this question:

FAQ: “Which antibiotics are less liable to cause an A-Fib attack? How is Clindamycin for dental work? In the past I reacted to Azithromycin and Advil.”

Our A-Fib Advisory Board Offers Expert Opinions

One EP’s response: “There is no particular association that I can think of or have seen with antibiotics, but likely more of a personal idiosyncratic reaction to the drug. Everybody is different and has a different trigger.”

From another EP: “Most [antibiotics] do not change the way the heart’s electrical system functions other than prolonging the QT interval, which should have the opposite effect. In the quinolone family, (antibiotics) like Levofloxacin and Ciprofloxacin act like antiarrhythmics.

However, some antibiotics have worse gastric tolerance effects like Azithromycin and Erythromycin which can become a trigger for A-Fib by GI stimulation such as nausea or reflux. Medication to counter that side effect can be used, such as acid reducers.”

Continue reading the experts’ answers to this question…and my summary of their opinions, go to my FAQ: A-Fib Drug Therapy: Medications->

We’ve Got Answers: Browse Our Q&As About Catheter Ablation for Atrial Fibrillation

After reading our page about Catheter Ablation: Pulmonary Vein Ablation, you may have many questions. At A-Fib.com, we have answered thousands of questions from A-Fib patients—many of the same questions you may have.

In the realm of catheter ablation, the range of issues and questions can be staggering. Topics including RF energy vs Cryo, enlarged heart and heart failure, PV vs non-PV potentials/triggers, recurrences, O.R. Reports and many more.

At A-Fib.com, we provide answers. Here are a few of the questions we answer in FAQ: Catheter Ablation Procedures:

Steve S. Ryan observing ablation by Dr. Sidney Peykar, Cardiac Arrhythmia Institute

Radiation exposure:How dangerous is the fluoroscopy radiation during an ablation? I’m worried about radiation exposure.”

Blanking Period:How long before you know a Pulmonary Vein Ablation procedure is a success?

Clots/Blood Thinners: “I was told that I will have to take an anticoagulant for about 2-3 months after my ablation. Afterwards shouldn’t there be even less need for a prescription anticoagulant rather than more?”

Non-PV Triggers:Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots?

 A-Fib cure?I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a ‘cure.

Browse our Q&A: Catheter Ablation: Pulmonary Vein Ablation, CyroBalloon Ablation

Additional topics we cover: the heart’s blood pumping capacity, the age range for a successful ablation, time length of a typical ablation, developing a clot during an ablation, resuming ‘normal’ exercise after a PV, who’s a candidate for a Pulmonary Vein Ablation, and more.

Go to FAQ About A-Fib Treatments Options: Catheter Ablation Procedures to browse all our posted questions and ‘click’ on any question to jump to the answer.

More Categories of Question & Answers

For all our Q & A lists, go to our page Frequently Asked Questions (FAQs) by Patients with Atrial Fibrillation.

FAQ: Which antibiotics can cause an A-Fib attack?

FAQs A-Fib Drug Therapy: Medications

Drug Therapies for Atrial Fibrillation, A-Fib, Afib“Which antibiotics are less liable to cause an A-Fib attack? How is Clindamycin for dental work? In the past I reacted to Azithromycin and Advil.

To answer these questions, I turned to members of our world-wide A-Fib.com Advisory Board. Several EPs shared their opinions, research data and insights from their practices.

Expert Opinions from Several Members of our A-Fib Advisory Board:

One EP’s response: “There is no particular association that I can think of or have seen with antibiotics, but likely more of a personal idiosyncratic reaction to the drug. Everybody is different and has a different trigger.”

Another EP wrote: Most antibiotics are well tolerated by patients with A-Fib.”

Most [antibiotics] do not change the way the heart’s electrical system functions other than prolonging the QT interval, which should have the opposite effect…act like antiarrhythmics.

A well-known authority on pharmaceuticals and A-Fib stated: “I know of NO data to prove a link between any antibiotic and A-Fib.”

From another EP: “Most [antibiotics] do not change the way the heart’s electrical system functions other than prolonging the QT interval, which should have the opposite effect. In the quinolone family, (antibiotics) like Levofloxacin and Ciprofloxacin act like antiarrhythmics.

However, some antibiotics have worse gastric tolerance effects like Azithromycin and Erythromycin which can become a trigger for A-Fib by GI stimulation such as nausea or reflux. Medication to counter that side effect can be used, such as acid reducers.”

One EP called our attention to a study that focused on ventricular arrhythmia rather than on A-Fib. (Ventricular arrhythmias can kill you, while an attack of A-Fib usually isn’t life threatening):

“There have been reports of higher rates of ventricular arrhythmias with certain antibiotics (macrolides like Azithromycin and fluoroquinolones like Levofloxacin). It’s possible similar results could be found if looking for atrial arrhythmias, too. (The FDA warned of the risks of possibly lethal heart rhythm when taking Azithromycin or Levofloxacin. [Rao and colleagues.] But the absolute risks were relatively low.)

It’s much more likely that the underlying infection or illness causes A-Fib rather than the antibiotic used to treat it.

This EP further clarified:

A-Fib is more likely to start during times of physical stress, such as after surgery or when your body is fighting an infection. It’s much more likely that the underlying infection or illness causes A-Fib rather than the antibiotic used to treat the infection.”

The General Consensus on Antibiotics and A-Fib

At this time, we can’t identify antibiotics that cause or trigger A-Fib in most patients.

According to most authorities in the A-Fib field, an A-Fib patient’s negative reaction to a particular antibiotic is most likely an individual idiosyncratic response rather than a generalized, population-wide phenomenon.

Thanks to Our A-Fib Advisory Board

I am deeply indebted to these cardiac electrophysiologists and others who offer me their counsel in publishing A-Fib.com. When I have a tough question, I can button hole them at a medical conference, send an email, or telephone them.

While not always agreeing with all my positions, these doctors try to point me in the right direction. It is my honor to acknowledge and thank the world-wide members of the A-Fib.com Advisory Board.

For a list of members, go to the A-Fib.com Advisory Board.

Resources for this Article

Return to FAQ Drug Therapies
If you find any errors on this page, email us. Y Last updated: Monday, March 26, 2018

 

At Medical Centers: Why to Always Ask for a Specific EP

In talking with A-Fib patients, I’ve found a disturbing trend when they seek an Electrophysiologist (EP) at a medical center when they don’t have the name of a specific doctor.

Often the medical center’s office will assign the newest and/or least experienced EP on staff.

Not good. Instead, you want an experienced EP with a high success rate at getting A-Fib patients back into normal rhythm. (You deserve nothing less.)

Your Search for the Right EP

First, seek recommendations from your General Practitioner (GP) or cardiologist. If you know nurses or staff who work in the cardiology field, they can be great resources. Ask for referrals from other A-Fib patients.

Begin your own research with our page, Find the Right Doctor for You. Then check our Directory of Doctors Treating A-Fib.

All EPs Are Not Equal

After you’ve done your research, you’ll have a list of EPs you know are more experienced in getting A-Fib patients back into normal sinus rhythm. (For example, someone with the initials FHRS after his name, and/or a ‘Castle Connolly Top Doctor’).

Then, you can contact a medical center and ask for a particular EP.

Especially when you are seeking an ablation, all EPs are not equal. Selecting the right EP isn’t like getting a haircut at SuperCuts where any stylist will do.

Left Atrial Appendage (LAA): An Under-Recognized Trigger Site of Atrial Fibrillation

Recurrence of A-Fib after an ablation is very disappointing and frustrating both for patients and for EPs performing the ablation.

A link to the source of A-Fib recurrence may have been found. A study by Dr. Di Biase and his colleagues established that the LAA is responsible for a great deal of A-Fib recurrence.

Research: LAA Responsible for 27% of Recurrences

The multi-center study enrolled patients at leading medical centers in Austin, Texas, San Francisco and Palo Alto, Calif, Rome and Venice, Italy, Cleveland and Akron, Ohio.

In the study of 987 patients undergoing redo catheter ablations, 266 (27%) showed a prevalence of A-Fib triggers firing from the LAA.

In 32+% of these 266 patients, the LAA was the only source of arrhythmia signals.

Trial Design of LAA for Recurrences

The 266 patients were divided into three groups with different treatments. Each group was followed for 12+ months with these results:

  • Group 1. The LAA was not ablated (isolated); 74% of this group had recurrences of A-Fib.
  • Group 2. The LAA was ablated with focal lesions. 68% of this group had recurrences of A-Fib.
  • Group 3. The LAA was ablated by a circular catheter at the ostium of the LAA. 15% of this group had recurrences of A-Fib.

Trial Findings: LAA Responsible for Much A-FibLeft Atrial Appendage heart illustration

While this study was limited, as it only looked at redo ablations and recurrences, it’s significant. The patients (Group 3) who were ablated by a circular catheter at the ostium of the LAA, had a recurrence rate of only 15%!

Compared to 68% and 74%, this is a major, significant reduction in recurrences. This is great news for A-Fib patients undergoing a catheter ablation.

Trial results indicate that the LAA is responsible for a great deal of arrhythmia signals, probably more than any other area of the heart.

A-Fib Ablations: Check LAA for Non-PV Signals

Many EPs today aren’t aware of the importance of the LAA as a source of A-Fib signals and never even look at the LAA when doing an ablation. In the words of the study’s authors, “the LAA is an underestimated site of initiation of atrial fibrillation.

It’s good news that an increasing number of EPs after performing a PVI, then as their second step, map and ablate the LAA. This is especially in cases of persistent A-Fib and those with non-PV triggers. After the PVs are isolated, the LAA should be the next place to look. (Make sure your EP is one those who check the LAA!)

What This Means to Ablation Patients

This research is important not just for patients undergoing a redo catheter ablation but for any A-Fib patient seeking a catheter ablation.

Important when selecting your EP: When having a catheter ablation, no matter what kind of A-Fib you have, make sure your EP knows how, is experienced at, and routinely maps and ablates the LAA.

This may produce a more successful ablation and save you from a recurrence of A-Fib.

To learn more about the Left Atrial Appendage, see my article, The Role of the Left Atrial Appendage (LAA) & Removal Issues.

Resources for this Article

Updated Video: Zio Patch Single-Use Ambulatory Cardiac Monitor

The Zio® Patch by iRhythm is an interesting advancement in single-use ambulatory heart monitors. It looks like a big band-aid! After use, you return it to your doctor for downloading of the data.

The ZIO XT Patch

My first-hand experience: I wore one awhile back, after a prostate exam when my heart appeared to briefly be in A-Fib. As a followup, my cardiologist had me wear a Zio® Patch for two weeks. Result: no A-Fib! It turned out to be a one-time occurrence brought on by the medical test.

Updated Video: Zio® XT Patch

We’ve posted an updated video of the the Zio® XT Patch (iRhythm):

Patient with a Zio Patchvo

Description: The Zio® Patch cardiac monitor (iRhythm) looks similar to a 2-by-5-inch adhesive bandage and sticks to a patient’s chest.
In the video, Electrophysiologists, Dr Parri Dominic and Dr Ryan Jones of LSU Health Sciences Center, talk about this single-use ambulatory, continuously cardiac monitor that records for up to 14 days. No need to removal during exercise, sleeping or bathing. (2:04 min.) Posted by University Health News Network. Go to video->

At 55, A-Fib After Underwater Hockey, Then 2 Failed Ablations & a 3rd Using the ECGI Vest

By Martin Johnson, Champaign, IL. March 2018
With a post-script by Dr. Phillip Cuculich, Barnes-Jewish/Washington Un.

Martin Johnson

“My first A-Fib attack that I noticed, occurred in 2003 when I was 55 years old during a game of underwater hockey, an extreme sport requiring swimming under water while pushing a lead puck from one end of the pool to the other.

At first, I thought “well I did just swim 25 yards under water as fast as I could, so maybe this is just normal”. It lasted about 20 seconds.

The attacks quickly increased their duration to a couple hours each over the next couple months. I was forced to give up the game I’d been playing since age 37. I switched sports to softball, but that soon became impossible too, as I got an A-Fib attack every single game (but oddly, never at a practice).

A-Fib Progresses―Attack Just Sitting at Desk

For the first couple of years I only got attacks after physical exertion. As time went on, less and less exertion was required to trigger one.

I had my first attack without any kind of physical exertion while sitting at my desk at work. It scared me enough to see the local EP who recommended that I get an ablation. I thought that was too aggressive and instead started to try various drugs.

“My EP’s prognosis was―’ever more often, ever longer attacks until I would be in permanent A-Fib’”.

After going through 6 different drugs, most of which had no effect, one of which almost killed me and another that modified my attacks, I had no net improvement. My EP’s prognosis was “ever more often, ever longer attacks until I would be in permanent A-Fib”.

By 2010, I was getting approximately 24-hour long attacks approximately every four days plus occasional attacks triggered by physical exertion.

My First Ablation

I had my first RF ablation in July of 2010. I asked the EP if I should be in my natural A-Fib before the ablation, so that he could locate the problem cells. He said ‘no’. Instead, he induced A-Fib chemically. His approach was to isolate the PVs and draw several other lines in the left atrium. He then ablated the cells that he could detect taking part in the A-Fib that he induced.

He successfully got my heart back into Sinus Rhythm (SR), and was unable to further induce A-Fib. His OR report says that he expected this to have been a cure. (An O.R. [Operating Room] report describes what the EP did during the ablation.)

Two hours after the ablation, I was in A-Fib again.

In A-Fib Again―Leads to a Second Ablation

My A-Fib attack timing continued without letup— 24-hour-long attacks every 4 days. I agreed to a second ablation 6 months later.

“Two hours after the ablation, I was in A-Fib again.”

The OR Report for the second ablation was essentially the same as the first, and so were the results. After both ablations, I acquired new arrhythmias that annoyed me even while not in A-Fib. After about 6 months, the new arrhythmias abated, and my A-Fib pattern changed to 24 hours every 7 days—a small but welcome improvement.

Over the next five years, the attacks became longer and more frequent— by Jan 2016, I had 45 hours of A-Fib every 7 days.

Third Ablation? I Needed an Edge

Still I was not optimistic about a third ablation considering my previous poor results.

Medtronic ECGI vest

I decided I needed an edge—something that might be able to find whatever oddball A-Fib cause made me difficult to cure. The one thing that stuck out in my reading was the Medtronic ECGI vest used in Bordeaux, France by Dr Haissaguerre and others. [See How ECGI (Non-Invasive Electrocardiographic Imaging) Works.]

The 256 electrode ECGI vest enabled the graphic display of the electrical activity of the heart passively and totally non-invasively. Unfortunately, Dr Haissaguerre’s office would not respond to any of my attempts to contact him. And I learned that the FDA would not permit the use of the vest in the US as part of an ablation procedure.

Travel to St. Louis Where the ECGI Vest Was Invented

It seemed that all doors to the vest were shut. After some investigation, I discovered that the vest had actually been invented in the US at Washington Un. in St. Louis, MO. In January 2016

“I volunteered for a study…that might help me get use of the vest in spite of the FDA.”

I called up the inventor’s lab to get as much information as I could. I volunteered for a study with the hope of making connections that might someday help me get use of the vest in spite of the FDA.

In January 2017, I went to St Louis and got a CT scan and a vest recording for the study I had volunteered for. While there, I noticed a Dr. Cuculich come into the lab to borrow a vest. I immediately thought, this is the guy I need to keep track of.

FDA Approves Medtronic ECGI Vest―My New Hope!

Then the next month, Feb 2017, the FDA approved a commercial version of the vest made by Medtronic for use with A-Fib ablation.

By this time, I was having 48 hour attacks every 4 days. I called Medtronic to get a list of who in the US had bought the vest and who had any experience using it. To my relief, Barnes-Jewish Hospital in St Louis was one of only four buyers, and Dr Cuculich already had experience using the vest on non-A-Fib applications.

Now that I had located a possible vest practitioner, I still had to resolve other concerns. In particular, even Dr Haissaguerre in France didn’t use the vest on paroxysmal A-Fibbers. He only used the vest on patients with permanent A-Fib. I don’t know why. I was convinced that being in my natural A-Fib and not in chemically induced A-Fib, was essential to find the real causes. I also knew that I could put myself into A-Fib by physical exertion.

BisenseWebster Smart Catheter illustrations

Example of Contact force catheter (Biosense Webster)

Another Technology Edge: The Contact Force Catheter

Another technology that seemed important was the technique of dragging the catheter in order to burn a continuous line, rather than trying to burn individual dots. To help with this, a contact force catheter also seemed necessary. I first became aware of this due to a paper written by Dr Natale of Austin, TX. (see Resources below for article.)

A Concern: I Don’t Want to Lose My LAA

Another concern of mine was the insistence by some EPs to electrically isolate the Left Atrial Appendage (LAA).

“…in my mind…if the ablation worked, there would be no advantage to having closed off the LAA.”

During A-Fib, the blood in the LAA becomes stagnant, permitting the formation of clots.

But cutting off incompletely understood parts of one’s heart seemed exceedingly rash. Also, if the ablation worked, there would be no advantage to having closed off the LAA. So, closing off the LAA was just preparing for a failed ablation, in my mind.

About the Left Atrial Appendage (LAA)

What little is known about the LAA includes the fact that it is the source of heart stem cells needed for repair of the heart.

It was once thought that the heart cells you died with were the same ones you were born with. The latest belief is that about 40% of your heart is replaced during a full life.

This is a function I did not want to lose.

The LAA is also the source of a hormone which helps control blood pressure. The LAA also has a pumping function in parallel with the Left Atrium. And electrically isolating the LAA can often significantly reduce the contractile function of the LAA, thus making it a source of clots even when the heart is not in A-Fib.

Consulting Dr. Phillip Cuculich at Barnes-Jewish/Washington Un.

I called up Barnes-Jewish to inquire about my above listed concerns. Dr Cuculich called back and assured me that he was able and willing to meet all these requests:

1) Use the ECGI vest during ablation even though I’m paroxysmal;
2) To expect me to be in my organic A-Fib;
3) After getting me into Normal Sinus Rhythm, chemical induction of A-Fib was OK to track down more problems;
4) Use a contact force catheter and draw continuous lines rather than dots;
5) Leave my LAA electrically and physically intact.

Third Ablation―Running Up Flights of Stairs

The night before the scheduled ablation, I ran up and down a flight of stairs ten times which put me in my organic A-Fib in preparation for the following morning’s ablation.

On Nov 2, 2017, two Medtronic technicians fitted the 3-piece vest onto my torso. The ablation procedure took 5 hours—a lot longer than Dr Cuculich was planning on.

I woke up in NSR! The doctor noted that an A-Fib source in a pulmonary vein was active, but was already successfully being blocked by the ablation.

In Normal Sinus, But Short Bursts of A-Fib

Since the ablation 3.5 months ago, I have had about 15 A-Fib attacks totaling about 7 hours of A-Fib. [It’s not uncommon for A-Fib to reoccur during the three month ‘blanking period’ following an ablation.]

I believe every attack was triggered by drinking cold water. It took me a while to figure that out. I have not had an attack for the last month, during which I was able to remember ‘no cold water’!

Lessons Learned

For future reference: I read that Dr Cuculich was the lead investigator in a study of a totally non-invasive ablation procedure that uses the Medtronic vest to find the problems and ‘multi-beam focused radiation’ to ablate the errant heart cells.

I’m hoping that if I my A-Fib comes back, that the FDA won’t have been as slow permitting this new method, as they were with the vest (see Resources below for link.

In light of my experience, I would recommend that no one get an ablation without the advantage of the Medtronic ECGI vest. Without it, the EP is only guessing.

Using canonical ablation patterns that might have worked on some group of A-Fibbers, or using the old fashioned way of dragging a sensing catheter along the entire inner surface of a beating heart looking for electrical anomalies, is laughable to me.

It’s no wonder that my first EP couldn’t find the A-Fib sources inside my coronary sinus and right atrium. I welcome your emails.”

Marty Johnson
martyj1949(at)yahoo.com

Comments from Dr. Phillip Cuculic

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

“Thank you, Steve, for the chance to reply [to Martin’s A-Fib story]. And thank you, Martin, for sharing your story with the world. Brave patients and advocates like you are a powerful combination in today’s world of medicine.

Our understanding of any arrhythmia mechanism falls into two bins: the initiating event (triggers) and the sustaining circuit.

Over the past several decades, invasive procedures have identified common locations that harbor AF triggers, which is how pulmonary vein isolation has been an effective procedure to control AF for most patients. In general, we as a field have struggled in identifying reproducible non-PV triggers and the sustaining AF circuits.

One reason for our struggle is the tools with which we measure. A second reason is that each person’s AF is different, so the findings of one group of patients is not easily applicable to an individual patient that I meet for consultation.

Martin’s experience with noninvasive ECGI is a wonderful example of personalized medicine: treating an individual patient’s AF physiology. Credit for the development and clinical validation of this technology goes to the scientists, clinicians and industry development teams which include Dr. Yoram Rudy (Washington University), the amazing scientists who graduated from his lab, the intrepid clinical and investigational teams in Bordeaux, France, and the hard-working developers at CardioInsight and Medtronic.

Presently, thoughtful application of noninvasive ECGI is getting us closer to personalized AF treatment. Further development, testing, and refinement of the ECGI system is underway. While there is much more to accomplish in understanding the critical components of each individual patient’s AF, one cannot help but hear the hope dripping from the story that Martin shared.”

Editor’s Comments
I admire Martin’s tenacity in seeking his A-Fib cure after two failed catheter ablations. He educated himself about his disease and its treatments. Then he sought out an EP who would meet his needs, even drawing up a five-point check list to discuss before his third ablation. Well done, Martin!
Martin’s O.R. Report: Dr. Cuculich found all Martin’s PV’s were still not isolated or had re-connected. After his two previous ablations, all Martin’s PVs had connected/re-connected. Dr. Cuculich also found many gaps in Martin’s previous roof and mitral isthmus ablation lines.
ECGI Vest Found Hard-To-Map Drivers: The Medtronic ECGI Vest mapping system found Non-PV driver areas in Martin’s heart that easily could have escaped notice with routine mapping systems, areas such as the Coronary Sinus, Left Superior Pulmonary Vein and lateral Right Atrium.
During Dr. Cuculich’s ablation, Martin’s A-Fib/Flutter terminated when his Coronary Sinus was effectively ablated and isolated. This is considered the best outcome of an ablation. Most EPs would have stopped at this point. But because the Medtronic ECGI vest had indicated there were more A-Fib signal sources not yet ablated, Dr. Cuculich ablated those areas as well.
Medtronic ECGI Vest Very Effective! Martin’s A-Fib was a difficult case after two failed ablations. Instead of the usually 2-3-hour ablation, Martin’s took 5 hours, probably because the previous 2 ablation lesions made the third ablation more complicated.
The Medtronic ECGI Vest seems to be a major advance and improvement in the treatment of A-Fib. It certainly worked in Martin’s case. But at this time, few centers in the U.S. are using it and are only beginning to develop significant experience. This is because Medtronic wants the system to work as best as possible before making it more widely available.
What this means to patients: If you have persistent A-Fib or would be considered a potentially difficult case, try to find a center or EP with experience using the Medtronic ECGI Vest (even though you may have to travel.) It seems to be the next major advance and best mapping/ablation system on the market.

References for this Article

Kolata, G. A ‘Game Changer’ for Patients With Irregular Heart Rhythm. The NewYorkTimes.com, Dec. 13, 2017. https://www.nytimes.com/2017/12/13/health/heartbeat-tachycardia-radiation.html

Cuculich, P. S., et al. Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia. December 14, 2017. N Engl J Med 2017; 377:2325-2336. DOI: 10.1056/NEJMoa1613773. http://www.nejm.org/doi/full/10.1056/NEJMoa1613773

Ryan, S. The New Era of Catheter Ablation Technology: Force Sensing Catheters. A-Fib.com http://a-fib.com/moussa-mansour-md-force-sensing-catheters-2014-bafs/

Ryan, S. The Role of the Left Atrial Appendage (LAA) & Removal Issues. A-Fib.com http://a-fib.com/left-atrial-appendage-role-and-removal-issues/

Natale, A., et al. Paroxysmal AF Catheter Ablation With a Contact Force Sensing Catheter: Results of the Prospective, Multicenter SMART-AF Trial. Journal of the American College of Cardiology, 2014. ISSN: 1558-3597, Vol: 64, Issue: 7, Page: 647-56. https://doi.org/10.1016/j.jacc.2014.04.072

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

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

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

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

Focal impulse and rotor modulation (FIRM)

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

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

REAFFIRM Trial Design

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

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

Review All My Reports

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

My 2018 reports

2018 AF Symposium My Last 2 Live Procedures Reports

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

Amplatzer Anulet

Installing an Amplatzer™ Amulet™ LAA Occluder

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

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

CryoBalloon catheter

CryoBalloon catheter

CryoBalloon Catheter for Isolation of the LAA

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

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

Read My Other Live Case Reports

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

My 2018 reports: more to come

Patients with A-Fib and Kidney Disease: Should You be on Blood Thinners?

If you have Atrial Fibrillation and also suffer from Chronic Kidney Disease (CKG), beware! Being on an anticoagulant may make you more prone to stroke. That’s according to UK researchers.

In a newly published retrospective study from England (The United Kingdom), 7,000 patients over age 65 with chronic kidney disease who later developed A-Fib had more strokes (and hemorrhage bleeding) than those not taking anticoagulants.

Anticoagulant may make you more prone to stroke.

In fact, patients taking anticoagulants were 2.6 times as likely to have a stroke (and 2.4 times as likely to have major hemorrhagic bleeding).

Reduced Kidney Function and Atrial Fibrillation

Reduced kidney function or chronic kidney disease is very common in older people. Chronic kidney disease (CKD) and Atrial Fibrillation (A-Fib) often co-exist. A-Fib can promote or accelerate the progression of chronic kidney disease.

Worldwide, it’s estimated that 15–20% of patients with chronic kidney disease (CKD) also have Atrial Fibrillation.

Research Conclusion

According to the study’s first author, Dr. Shankar Kumar of the UCL Center for Medical Imaging, London:

“As we found in this particular group, their medication (anticoagulant) seems to do the opposite of its intended effect.

…Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation.”

A-Fib and Anticoagulation: First Check for Reduced Kidney Function 

How to measure if your kidneys are working? A Glomerular Filtration Rate [GFR) of 60 or higher is normal, while a GFR below 60 may mean kidney disease.

This study only dealt with Chronic Kidney Disease (CKD). But common sense dictates that the findings of this study may also affect anyone with reduced kidney function.

In the early stages of Chronic Kidney Disease, there may be few signs or symptoms. CKD may not become apparent until kidney function is significantly impaired.

From this study, we can say it’s imperative that anyone with A-Fib especially older people, should be checked for reduced or chronic kidney disease before being put on anticoagulants.

Alternatives to Anticoagulants

This study points out the difficulty for A-Fib patients taking anticoagulants who also have chronic kidney disease: The anticoagulants meant to prevent stroke actually increase stroke risk and hemorrhage bleeding.

If you’re in this situation, you may want to consider these two options:

1. Closure of the Left Atrial Appendage (where most A-Fib clots originate). An occlusion device like a Watchman may be an alternative to anticoagulants. (For more, see my article, The Watchman™ Device: An Alternative to Blood Thinners);

2. Free yourself from A-Fib. Consider a catheter ablation procedure (or mini-maze surgery). Reasoning: if you no longer have A-Fib, you can’t have an ‘A-Fib-related’ stroke.

But know that even without A-Fib, you can still have a stroke from other causes. (Right now, we don’t have a therapy that will absolutely guarantee you will never have a stroke.)

What This Means for A-Fib Patients

For A-Fib patients who also have chronic kidney disease, being on an anticoagulant may make you more prone to stroke, not less.

Accordingly, if you have A-Fib and are taking anticoagulants, ask your doctor if you have been checked for ‘reduced kidney function’.

And if in the future, you develop reduced kidney function, discuss these research findings with your doctors (print a copy of this post and include the ‘References for this Article’ below).

Paradox: If you have kidney disease, the anticoagulants meant to prevent stroke actually increase stroke risk and hemorrhage bleeding.

Resources for this Article

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

by Steve S. Ryan, PhD.

B. Knight MD

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

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

Isolating the Left Atrial Appendage

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

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

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

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

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

Back to 2018 AF Symposium Reports

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

by Steve S. Ryan, PhD

John Hummel MD

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

Focal impulse and rotor modulation (FIRM)

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

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

REAFFIRM Trial Design

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

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

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

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

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

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

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

What this Trial Means for Patients

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

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

Back to 2018 AF Symposium Reports

New Video: The Maze Open-Heart Surgery From The Cleveland Clinic

In a new video we’ve added to our library, cardiac surgeon Edward Soltesz, MD, discusses who is a good candidate for the Maze surgical-based treatment for Atrial Fibrillation.

Image from the video ‘The Maze Open-Heart Surgery’

The full Maze open-heart surgery is typically performed in conjunction with surgery to correct another heart condition such as valve disease or coronary disease but can also be performed as a standalone treatment.

Interviews, animation, illustrations and surgical footage. (3:19) Produced and posted by the Cleveland Clinic. Go to video->

Related Videos: Mini-Maze Surgery

You may also be interested in our videos about the Mini-Maze:

Mini-Maze Ablation for Persistent A-Fib: With Cardiac Surgeon Dr. Dipin Gupta
In-Depth: Mini-Maze Surgery: Inside the O.R. with Dr. William Harris, Cardiovascular Surgeon

A-Fib Library of Videos and Animations

We have carefully selected the A-Fib-related videos in our Video Library. They have been selected for the reader who learns visually through motion graphics, audio, and personal interviews.

Our collection of short videos are organized loosely into three levels: introductory/basic, intermediate and in-depth/advanced. Click to browse our video library.

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

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

Tom De Potter MD

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

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

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

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

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

Coherex WaveCrest Video

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

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

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

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

Back to 2018 AF Symposium Reports

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

by Steve S. Ryan, PhD.

Illustration: Amplatzer Amulet in LAA

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

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

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

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

Live From Milan, Italy

Claudio Tondo, MD

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

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

Amplatzer Amulet Features

Amplatzer™ Amulet™ illustration at A-Fib.com

Amplatzer™ Amulet™

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

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

Inserting the Amplatzer LAA Occluder

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

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

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

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

Amplatzer™ Amulet™ Video

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

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

Two LAA occluder devices

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

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

Back to 2018 AF Symposium Reports

2018 AF Symposium Live Procedures: Four New Reports

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

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

AF Symposium 5-floor-to-ceiling video monitors

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

My Favorite and My Most Difficult

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

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

Four New Live Case Reports

EP and attendee during live case

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

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

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

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

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

Just Like Being There

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

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

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

My 2018 reports: more to come

Follow Us
facebook - A-Fib.comtwitter - A-Fib.comlinkedin  - A-Fib.compinterest  - A-Fib.comYouTube: A-Fib Can be Cured!  - A-Fib.com


A-Fib.com is a
501(c)(3) Nonprofit



Your support is needed. Every donation helps, even just $1.00.



A-Fib.com top rated by Healthline.com for fourth year 2014  2015  2016  2017

A-Fib.com Mission Statement
We Need You

Mug - Seek your cure - Beat Your A-Fib 200 pix wide at 300 resEncourage others
with A-Fib
click to order

Home | The A-Fib Coach | Help Support A-Fib.com | A-Fib News Archive | Tell Us What You think | Press Room | GuideStar Seal | HON certification | Disclosures | Terms of Use | Privacy Policy