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


Treatments

FAQ: After Ablation—What’s my Chance of Staying A-Fib Free?

There is a tendency for ablated heart tissue to heal itself, regrow the ablated tissue, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

An A-Fib.com reader sent me this question about recurrence of his A-Fib after a successful ablation:

Illustration of catheter ablation

Illustration of catheter ablation of pulmonary vein

“Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

Regrowth/Reconnection of Ablated Heart Tissue

I think your chances of staying A-Fib free are pretty good.

If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again. When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. But it’s too early in the history of PVA(I)s to say this definitively. …read the rest of my answer.

In Persistent A-Fib? Time Matters: Ablate Sooner for Better Outcomes

Note: This research study is important if you have Persistent A-Fib or your Paroxysmal A-Fib has progressed to Persistent A-Fib.

The Cost of Waiting to Ablate

In patients with persistent atrial fibrillation undergoing ablation, the time interval between the first diagnosis of persistent A-Fib and the catheter ablation procedure had a strong association with the ablation outcomes.

Cleveland Clinic researchers found that shorter diagnosis-to-ablation time spans were associated with better outcomes. Longer diagnosis-to-ablation times was associated with a greater degree of atrial remodeling.

When A-Fib becomes persistent A-Fib, the ‘first diagnosis-to-ablation time span’ had a stronger impact on outcomes than the time spent in paroxysmal A-Fib.

According to electrophysiologist Dr. Oussama Wazni, “once the diagnosis of atrial fibrillation is made, it’s important not to spend too much time trying to keep a patient in normal rhythm with medical [drug] therapy” before referring for radio-frequency ablation.” Dr. Wazni is Co-Director of the Center for Atrial Fibrillation at the Cleveland Clinic.

His comments are based on the published analysis of two-year outcomes among 1,241 consecutive patients undergoing first-time ablation of persistent atrial fibrillation over an eight-year period at Cleveland Clinic. All patients had successful isolation of all 4 PVs (pulmonary veins), and the superior vena cava was isolated in 69.6%. In addition, Left Atrium ablations (including complex fractionated electrograms) were performed in 65.6% of patients.

First Diagnosis-to-Ablation Time Span: The Shorter the Better

Importantly, the first diagnosis -to-ablation time interval (of persistent A-Fib) had a stronger impact on outcomes than the time spent with a paroxysmal A-Fib diagnosis or the duration of continuous A-Fib before the ablation procedure.

These findings suggest that A-Fib is a disease with a continuous spectrum…
The findings suggest that A-Fib is a disease with a continuous spectrum, with patients at the extreme end of that spectrum having higher arrhythmia recurrence rates after catheter ablation, whereas patients with shorter diagnosis-to-ablation times having lower recurrence rates.

The analysis was published in the Jan. 2016 issue of Circulation: Arrhythmia and Electrophysiology. (Read online or download as a PDF.)

VIDEO: Ablation for Persistent Atrial Fibrillation.  In this short video, Dr. Wazni describes the results of research showing that time interval between first diagnosis of persistent atrial fibrillation and catheter ablation had a strong association with ablation outcomes. (Posted by the Cleveland Clinic, Jan 2016; 3:11 min)

Reference for this Article

2017 AF Symposium: Live Case of Ablation with FIRM Mapping System

Dr David Wilber Loyola University

D. Wilber, MD

In a live case, Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. ‘FIRM’ stands for Focal Impulse and Rotor Modulation.

Patient background: The patient was a 54-year-old male in persistent A-Fib for 7 months, obese with a BMI of 31, hypertension, diabetes, and obstructive sleep apnea. He was symptomatic, with fatigue and decreased exercise tolerance. An MRI showed his Left Atrium was 15.5% fibrotic. (If using Dr. Nassir Marrouche’s Utah I–IV Classification System to rate the patient’s amount of fibrosis, this patient would be “Utah Stage 2”, i.e., a reasonable candidate for a catheter ablation.)

Voltage & FIRM Mapping: Rotors Ablated First

FIRM mapping display of left atrial rotor during atrial fibrillation.

FIRM mapping display of left atrial rotor during atrial fibrillation.

In live video streaming from Chicago, Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation (PVI).

He explained that the concept of terminating A-Fib during a PVI ablation doesn’t work with the FIRM system. Instead, he looks to ablate rotational areas (which are usually 2.2 cm across). He does by with using a Contact Force sensing catheter usually at 35 watts for 30 sec.

During this ablation, he found one rotor at the base of the Left Atrial Appendage (LAA). (In the followup panel discussion, Dr. Andrea Natale commented that his colleagues now look first for A-Fib signals in the LAA.)

FIRM Rotors Hard to See

VIDEO examples: Dr. Wilber showed a video using FIRM in which [even to my untrained eye] it was easy to see a rotor. But he showed other videos where the overlapping, swirling waves made it difficult to see where exactly a rotor was coming from.

Editor’s Comments:
This patient was at great risk of recurrence after a catheter ablation, because of his various illnesses (comorbidities). By restoring him to normal sinus rhythm, he would be able to exercise and develop life-changing habits to reduce his obesity, diabetes, and hypertension.
ECGI CardioInsight system: Focal and re-entrant driver maps

ECGI CardioInsight system: Focal and re-entrant driver maps

Topera FIRM vs Medtronic ECGI CardioInsight:  In comparison to the ECGI CardioInsight system where the rotors and focal sources are very obvious (even to untrained observers), the FIRM system display of rotors are often confusing and hard to identify. Dr. Wilber acknowledged that it takes study and experience with the FIRM system to use it effectively.
To me, the Topera FIRM system seems hard to use. In head-to-head competition with the Medtronic ECGI CardioInsight system, I predict the FIRM system will probably not survive.
The Medtronic ECGI CardioInsight system has been in limited use in Europe and in 2017 has begun a limited rollout in the U.S.

For more on the Medtronic ECGI CardioInsight, see my article: ECGI Mapping Now Available in U.S.

For more about Dr. Nassir Marrouche’s Utah I–IV Classification System, see my article: Fibrosis Risk and the U. of Utah/CARMA website.

Reference for this Article

NOAC or Warfarin for Valvular A-Fib?

Patients with ‘Valvular Atrial Fibrillation’ are often restricted from most A-Fib clinical studies and research. In particular, for NOAC trials, people with Valvular A-Fib have generally been excluded because they may have a higher rate of forming clots (e.g.: left atrial clots). 

“Valvular Atrial Fibrillation” refers to those A-Fib patients with artificial heart valves or mitral stenosis.

Like most A-Fib patients, Valvular A-Fib patients with bioprosthetic or mechanical valves have to be on an anticoagulant which up to now was restricted to warfarin. So, are the new NOACs an option?

Bioprosthetic valves are non-synthetic (usually porcine) devices used to replace a defective heart valve. Compared to mechanical valves, bioprosthetic valves are less likely to cause clots, but are more prone to structural degeneration (35% fail within 15 years).

Warfarin vs Edoxaban (NOAC)

A 2017 study showed that the Novel Oral Anticoagulant (NOAC) edoxaban (brand name: Savaysa) was safer than warfarin in preventing an A-Fib stroke in people with bioprosthetic heart valves.

Edoxaban 30 and 60 mg (Savaysa)

Edoxaban works by inhibiting factor Xa in the coagulation process. The lower dose (30 mg) was associated with a reduced rate of major bleeding, but not the higher dose (60 mg).

Compared to warfarin, edoxaban was associated with lower annual stroke rates, systemic embolic events, major bleeds, and deaths annually.

“Our analysis suggests that edoxaban appears to be a reasonable alternative to warfarin in patients with Afib and remote bioprosthetic valve implantation,” according to Dr. Robert P. Giugliano of Brigham and Women’s Hospital in Boston, MA.

Edoxaban Works With Bioprosthetic Valves But Not Mechanical Ones

For the first time, research indicates that a NOAC (edoxaban) can be used for Valvular A-Fib to prevent an A-Fib stroke―but only in the case of bioprosthetic (porcine) valves.

The NOAC, Edoxaban (Savaysa), was safer than warfarin for A-Fib patients with bioprosthetic valves.

With regards to mechanical valves, the authors cited a study in which dabigatran (Pradaxa) fared poorly in mechanical valves.

What About Other Factor Xa NOACs?

What about the other ‘factor Xa inhibitors’ such as Xarelto and Eliquis? Can they be used like edoxaban? Currently there is little clinical data on this subject. But since all three are factor Xa inhibitors, most likely they will be proven to be effective in A-Fib patients with bioprosthetic valves.

What Patients Need to Know

Do you have Valvular A-Fib and a bioprosthetic valve? Are you on warfarin? If being on warfarin is difficult for you, you now have a choice of anticoagulant. Ask your doctor about switching to the NOAC, edoxaban.

Reference for this Article

2017 AF Symposium: Movin’ it—Protecting the Esophagus During Ablation

2017 AF Symposium

Movin’ it: Protecting the Esophagus During Ablation

Live case presenters: Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt from the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, TX. Moderator: Dr. Andrea Natale.

Patient background: A 79-year-old female needed a ‘re-do’ second ablation. She had persistent A-Fib and hypertension. Her first ablation was August 15, 2016 where they couldn’t terminate her Flutter. Because the temperature probe in her esophagus showed a rise in temperature when they tried to ablate certain areas, “we were not as aggressive as we would have liked.”

The Danger: Esophageal Fistula

During an ablation, doctors take great precautions to not heat or injure the esophagus which lies behind the posterior wall of the left atrium. Injuring the esophagus can, in very rare cases, cause an atrial esophageal fistula which can be fatal.

Fear of causing esophageal injury can cause the EP to modify the ablation lesion set delivery, thereby reducing ablation success by:

1. Reducing the wattage or amount of energy delivered to the left atrium wall which causes less complete scarring; and/or

2. Relocating the ablation lesion to a less desirable area

For this patient: During her first ablation: the doctors noticed a rise in temperature of the probe inserted in her esophagus, so her doctors stopped ablating in that area. Consequently, the A-Fib signal source(s) in that area were not isolated effectively. Result: her A-Flutter was not terminated.

Solution: Esophageal Displacement Tool

The esophagus is not a rigid, inflexible pipe but rather like a hose made out of flexible muscle fibers. It can naturally migrate side-to-side 2-3 cm on its own.

For this live streaming ablation, a new esophagus displacement tool was used: the EsoSure Esophageal Retractor. The tool allows doctors to re-position a section of the esophagus away from the nearby heart tissue and avoid the heat generated during ablation.

The inventor of the device, Steven W. Miller, RN and EP nurse, demonstrated his device to me at the AF Symposium Exhibit Hall.

EsoSure Esophageal Retractor: Shape adjusts to body temperature at A-Fib.com

EsoSure Esophageal Retractor: Shape adjusts to body temperature

At room temperature, the stylet is fairly straight which allows it to be easily inserted into a commonly used gastric tube which is routinely placed down the esophagus by the anesthesia staff. But as the stylet warms to body temperature, it takes on a greater curve. He inserted the stylet into warmed water. You could see how the stylet changed shape and developed a greater curve.

Depending on how the stylet is positioned, it can displace the esophagus up to 2-3 cm to the left or right depending on each person’s anatomy.

Using the EsoSure Retractor, the EP can easily and safely move the esophagus away from any area being ablated. It is FDA approved and has been used by different practitioners more than 700 times without damaging the esophagus.

Live Case Using the EsoSure Retractor

In this re-do ablation, the 79-year-old female patient was in A-Fib when the ablation started. They cardioverted her, but she went right back into A-Fib.

Entrainment (pacing) mapping was used to identify non-PV triggers. Since they had to ablate in the posterior of the left atrium next to the esophagus, they simply moved the EsoSure Retractor up and down to displace the esophagus. It seemed very easy to do.

The EPs mentioned that, with the use of this displacement device, they could now ablate at a higher wattage without fear of harming the esophagus. They also ablated the Left Atrial Appendage area to restore her to sinus rhythm.

What Patients Need to Know

Displacing the esophagus is a major medical advance: The EsoSure Esophageal Retractor is a major medical advance that will significantly improve not only the safety but the effectiveness of catheter ablations. Compared to any other gear in the ablation lab, the EsoSure Retractor is inexpensive ($365-$395 depending on quantity ordered). Any EP lab can and should use it, (or something similar).

Esophagus injury: All too often the esophagus lies behind the right pulmonary vein openings. Doctors have to limit both the placement and the power of their lesions out of fear of damaging the esophagus.

But being able to move the esophagus solves this problem. Ablations will be more effective, and the danger of producing an Atrial Esophageal Fistula (while rare) will be greatly reduced, if not eliminated. It will also reduce ablation procedure time.

Ask your EP: If you are scheduling an ablation, ask your doctors about their plan to prevent esophageal injury.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Saturday, March 11, 2017

Reference for this Article

2017 AF Symposium LIVE VIDEO: Can Adding Fibrosis Improve Ablation Success?

Updated March 9: We added two new slides comparing the patient’s initial and subsequent DE-MRI images.

Report 13 from 2107 AF Symposium: In a live ablation from from Mass. General Hospital in Boston, Drs. Heist and Van Houzen demonstrated a pioneering strategy to treat Atrial Fibrillation patients with patchy fibrotic areas of tissue. This tissue perpetuates A-Fib.

First, a DE-MRI scan defines and measures the heart’s areas of fibrosis. Next, the doctors ablated (or filled in) these patchy areas with more fibrosis (i.e., ablation scarring) turning the patchy areas into dense fibrotic areas. Transforming patchy fibrotic tissue to dense fibrotic tissue stops A-Fib signals from perpetuating in that tissue.

It may seem counter-intuitive―create more fibrosis to make patients A-Fib free. Read more about this innovative strategy.

2017 AF Symposium Live Video: Adding Fibrosis to Improve Ablation Success?

2017 AF Symposium

Live Case: Can Adding Fibrosis Improve Ablation Success?

Updated March 13: We added two new slides.

Streaming video of an ablation by Drs. Kevin Heist and Nathan Van Houzen from Massachusetts General Hospital (MGH) in Boston, MA (moderator, Dr. Moussa Mansour).

Patient background: The case of a 62-year-old male with symptomatic persistent A-Fib, despite a previous ablation 8/9/2016. Propafenone, amiodarone, and an electrical cardioversion weren’t effective. The patient had been taken off amiodarone a week before this ablation. They cardioverted him into sinus rhythm to better measure areas of low voltage (areas of fibrosis). Low voltage areas were defined as less than 0.5 V.

Mapping Views: Lesions and Remaining Fibrosis From First Ablation

THE TOP SLIDE: The RF point-by-point ablation lesions from the patient’s first ablation done months before the live case.

RED dots represent a greater force or more time making the lesion; PINK dots represent a lower efficiency lesion due to proximity to the esophagus.

Some of these PINK dot area had reconnected and had to be re-ablated during the live case.

(“PA” is  the left atrium viewed from the back.)

THE BOTTOM SLIDE: The MRI done shortly before the live case. The BLUE areas are normal atrial tissue. The RED areas are fibrotic/scarred areas. Some of the red areas in this PA view were not ablated during the first procedure and represent spontaneous fibrosis.

Live: Ablating Areas of Fibrosis

In this live procedure from Boston, MA, Drs. Heist and Van Houzen did a normal PVI and found evidence that some areas from the patient’s previous ablation had reconnected.

The innovative aspect of this ablation is they also ablated areas of fibrosis. ‘Spontaneous fibrosis’ tends to be patchy in a way that perpetuates A-Fib.

Ablating or filling in these patchy areas with more fibrosis (i.e., ablation scarring) turns the patchy areas into dense fibrotic areas which can’t conduct or perpetuate A-Fib.

They first performed a Delayed Enhancement MRI (DE-MRI) scan of this patient’s heart in order to define and measure the areas of fibrosis.

The EPs then ablated (filled in) areas of this fibrosis, turning these patchy fibrotic regions into denser fibrotic areas. These dense fibrotic areas no longer conducted or perpetuated A-Fib.

Two months after the ablation the patient is doing well in sinus rhythm. Whereas after his first ablation, he experienced early recurrence.

What Patients Need to Know

Who Benefits from this Strategy? Adding or filling in patchy fibrotic areas with more fibrosis through ablation is a very innovative ablation strategy.

It is being applied to patients with persistent or persistent long-standing A-Fib who usually have more fibrosis, but is also being applied to paroxysmal patients who have had a durable (successful) PVI but are still in A-Fib (they often have some fibrotic areas).

The term ‘spontaneous fibrosis’ refers to fibrosis (scarring) which occurs naturally, that is, without a doctor’s procedural intervention.

Impractical for Diffused Fibrosis: This strategy doesn’t work if someone has a generalized distribution of fibrous tissue throughout their atrium. It would require ablation of the whole atrium creating too much fibrosis and causing other heart function problems.

Isn’t Creating More Fibrosis Dangerous for Patients? It certainly does seem counterintuitive―create more fibrosis to make patients A-Fib free. But we are looking at patients who already have patches of fibrosis. (If we could turn these fibrotic areas back into smooth heart muscle, then this strategy wouldn’t be necessary.)

This strategy can make people with difficult A-Fib cases A-Fib free, and make a huge difference for patients who have failed ablations.

While this strategy is exciting, we are only at the very beginning stages of this research.

Acknowledgements:

Nassir Marrouche MD

N. Marrouche MD

Dr. Nassir Marrouche: The concept of ablating areas of fibrosis was conceived by Dr. Nassir Marrouche of the University of Utah (CARMA). Dr. Marrouche has started DECAAF II, a clinical study on fibrosis to compare ablation of fibrosis areas to standard PVI ablation.

Known for the completed DECAAF study, Dr. Mansour is now collaborating with Dr. Marrouche on the DECAAF II study, and Massachusetts General Hospital (the originating site of this live streaming video) is one of the participating sites. For more, see my 2017 AF Symposium article A-Fib Increases Fibrosis.

Dr. Kevin Heist: I would like to thank Dr. Kevin Heist, Mass. General Hospital, for patiently explaining to me the concept, rationale and strategy of ablating areas of fibrosis. (I really needed his help!)

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Monday, March 13, 2017

Reference for this Article

2017 AF Symposium: LIVE Video Ablation With Non-Contact Catheter Mapping

The Acutus Medical Non-Contact basket catheter with multiple electrodes

The Acutus Medical Non-Contact basket catheter with multiple electrodes

Report 12 from 2107 AF Symposium: In a live case from Prague, the Czech Republic, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used Acutus Medical’s basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. …Read my full report…

Atrial Fibrillation and Atrial Flutter: Cause and Effect?

About Atrial Fibrillation and Atrial Flutter…are they linked? Does one precede the other? Can one procedure fix both? Can a typical catheter ablation fix both Atrial Fibrillation and Atrial Flutter at the same time? Can Maze surgery or Mini-maze surgery fix both?

Surgery vs. Ablation

In general, Atrial Flutter originates in the right atrium and Atrial Fibrillation in the left atrium.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter. If you have both A-Fib and A-Flutter, a Maze procedure needs to be followed by a catheter ablation to fix the Atrial Flutter.

A catheter ablation procedure for A-Flutter is relatively easy and it’s highly successful (95%). It usually involves making a single line in the right atrium which blocks the A-Flutter (Caviotricuspid Isthmus line).

A Catheter Ablation Two-Fer? 

If you are having a catheter ablation, many doctors make this Caviotricuspid Isthmus ablation line while doing an A-Fib ablation (in the left atrium)—even if you don’t have A-Flutter at the time.

Catheter inserted into the heart and through septum wall into Left Atria

Catheter inserted into the heart and through septum wall into Left Atria

Catheters enter the heart through the right atrium. At the beginning of a catheter ablation for atrial fibrillation, doctors enter the heart through the right atrium. While there they may elect to make the right atrium ablation line at this point which takes 10-20 minutes.

They then go through the wall separating the right and left atria (transseptal wall) to do the ablation for A-Fib in the left atrium. (Some doctors chose to place the right atrium ablation line at the end of an ablation when they withdraw from the left atrium into the right atrium.)

Some say one should “do no harm” and not make this right atrium ablation line if there is no A-Flutter. Saying it can always be done later in another catheter ablation at little risk to the patient.

Research: Are A-Fib and A-Flutter Linked?

While you can have A-Flutter without A-Fib, more often than not, they are linked. When you have A-Flutter, A-Fib often lurks in the background or develops later.

Patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

Some A-Flutter may originate in the left atrium, or the A-Flutter may mask A-Fib which may appear later after a successful A-Flutter ablation.

As many as half of all patients ablated for A-Flutter may later develop A-Fib.

In a small research study, patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

What Patients Need to Know

But right now we can’t say for sure if one causes the other. We do know that A-Flutter usually comes from the right atrium, while A-Fib usually comes from the left atrium.

Resources for this article

Live Case: Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

2017 AF Symposium

Live Case: Ablation Using Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

Illlustration: Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Video streaming of an ablation from Na Homolce Hospital in Prague, the Czech Republic with Drs. Peter Neuzil, Jan Petru, and Jan Skoda.

The doctors used a new high resolution mapping system from Acutus Medical to identify in real time where his A-Fib signals were coming from.

Patient background: A 68-year-old man in paroxysmal A-Fib had a CHA2DS2-VASc score of 4 with hypertension and a pulmonary embolism. He had had a PVI in January 2011 and a repeat PVI to fix gaps in April 2011. His A-Fib recurred in 2014. Electrical cardioversions didn’t work.

Non-Contact Mapping with Ultrasound-Electrode Catheter

VIDEO: For a more detailed explanation of the Non-Contact Dipole Density AcQ Imaging and Mapping, see the video from Acutus Medical.(1:54)

The Acutus Medical Non-Contact Dipole Density AcQ Imaging and Mapping catheter uses a basket catheter with multiple electrodes and ultrasound anatomy reconstruction.

‘Non-contact’ means the basket catheter can float freely in the left atrium and doesn’t have to be applied to the surface of the heart to generate A-Fib maps.

The basket catheter has six splines each with eight nodules that contain 48 ultrasound transducers and 48 electrodes. The ultrasound pings the atrium wall and rapidly produces a 3D left atrium anatomy.

Electrical Measurement: Dipole Density vs Voltage

For over one hundred years, voltage has been the major electrical measurement in cardiac medicine. The limitation with using voltage in electrophysiology is that the reading includes both the localized charge (Dipole Density) as well as the sum of the surrounding sources providing a broad, blended view of cardiac activity.

According to Acutus Medical, by eliminating these surrounding sources, and using dipole density (instead of voltage) the field of view becomes sharper and narrower.

This more precise electrical activation is displayed as a Dipole Density map on a 3D ultrasound reconstruction of the heart.

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Live Streaming Video: Ablation from Prague

In the live case, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used the basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. When they made a mitral isthmus line, the patient’s A-Fib terminated which restored him to normal sinus rhythm.

What Patients Need To Know

May Replace Contact Mapping: Non-contact mapping is a significant innovation in catheter ablation and may eventually replace existing contact mapping catheters and make ablations easier. It also seems to require less technical skill than in a traditional contact mapping system.

“Non-contact mapping is a significant innovation and may eventually replace existing contact mapping catheters.”—Steve Ryan

No Radiation & Instantaneous: Using ultrasound to produce a 3D rendering of the heart is innovative and could change the way the anatomy of the heart is generated for an ablation. And unlike a CT scan, it doesn’t use radiation. Also, unlike a CT scan, the ultrasound images of the heart are generated instantaneously in real-time.

Higher Resolution: Dipole Density mapping may prove to be a higher resolution system than current mapping systems.

Not Yet Available in U.S.: But don’t expect the Acutus Medical System to become available in the U.S. any time soon. It isn’t yet FDA approved or available for sale in the U.S.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Thursday, March 2, 2017

Reference for this Article

2017 AF Symposium: Three New Reports—Genetic A-Fib and LIVE Streaming Video Ablations

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

To my 2017 AF Symposium Overview, I added how we observed in-progress A-Fib procedures via streaming video from five locations spanning the globe, and heard from the EPs performing the ablations. Continue to the Video Overview…

Report 11: LIVE! Ablation Using CardioFocus Laser Balloon

CardioFocus HeartLight Laser Balloon catheter

CardioFocus HeartLight Laser Balloon catheter

Video streaming from Na Homolce Hospital in Prague, The Czech Republic. Drs. Peter Neuzil, Jan Petru and Jan Skoda did an ablation using the CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon (FDA approved April 4, 2016).

The doctors showed how they could directly see the Pulmonary Vein opening they were ablating (unlike RF and CryoBalloon systems). The center of the catheter has an endoscopic (looking inside) camera.

(To me, this is a major advantage and ground-breaking improvement for patients.)

Read more of my report, and see a short video clip with an actual view of the pulmonary veins during an ablation. …Continue reading my report….

Report 10: LIVE! Two Procedures—but Different Left Atrial Appendage Occlusion Devices

Featuring the Amplatz Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.

Amplatz Amulet occlusion device by St. Jude Medical - A-Fib.com

Amplatz Amulet occlusion device by St. Jude Medical

Live from Milan, we watched the doctors insert an Amplatz Amulet into the LAA of a 78-year-old women who had a high risk of bleeding.

These doctors did something I had never seen before. They made a physical model of the woman’s LAA, then showed how the Amplatz Amulet fit into the model. This helped AF Symposium attendees see how the Amplatz Amulet actually worked. …Continue reading my report…

Report 9: World-Wide Studies on Genetic A-Fib

DNA: Double helix graphic at A-Fib.com

Dr. Patrick Ellinor of Mass. General Hospital, Boston MA, reported the biggest news is that A-Fib genetic research is increasing exponentially. The AFGen Consortium website lists 37 different studies and world-wide institutions studying A-Fib genetics with over 70,000 cases. Within the next 10 years, Dr. Ellinor and his colleagues hope to identify over 100 different genetic loci for A-Fib.

Dr. Ellinor reported that using a genetic “fingerprint” of A-Fib helps to identify those patients at the greatest risk of a stroke. (There’s a 40% increased risk of developing A-Fib if a relative has it.)…Continue reading my report…

About the Annual AF Symposium

The annual AF Symposium brings together the world’s leading medical scientists, researchers and EPs to share recent advances in the treatment of atrial fibrillation. You can read all my summary reports on my 2017 AF Symposium page.

Videos: Arrhythmias Animations by St. Jude Medical

Three short animations: Atrial Flutter, Pacemaker, and Implantable Defibrillator (ICD) treatment options from St Jude Medical.

Atrial Flutter: Fast Heartbeat Arrhythmia (00:28)

Pacemaker Treatment Option (too slow of heart beat) (:49)

Implantable Defibrillator (ICD) Treatment Option (too fast heart beat) (:57) 


If you find any errors on this page, 
email us. Y Last updated: Sunday, February 19, 2017

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Video: A Live Case of Catheter Ablation for Long-Standing Persistent A-Fib Through 3D Mapping & ECG Images

Presented entirely through 3D mapping and ECG images, a live demo of ablation for long-standing, persistent A-Fib is followed from start to finish. Titles identify each step. No narration, music track only (I turned down the volume as the music track was distracting.)

3D mapping and ECG images show the technique of transseptal access, 3D mapping, PV isolation, and ablating additional drivers of AF in the posterior wall and left atrial appendage. (8:03) Produced by Dr. James Ong, Heart Rhythm Specialist of Southern California.

NOTE: Before viewing this video, you should already have some basic understanding of cardiac anatomy and A-Fib physiology.


YouTube video playback controls:
 
When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017 Return to Instructional A-Fib Videos and Animations

Video: When Drug Therapy Fails: Why Patients Consider Catheter Ablation

For Insidermedicine.com. Dr. Susan M. Sharma discusses why patients with atrial fibrillation turn to ablation when drug therapy doesn’t work. Presenting research findings by David J. Wilber and MD; Carlo Pappone, MD, Dr. Sharma discusses the success rates of drug therapy versus catheter ablation. (See transcript below.) (3:00 min.) Published Jan. 26, 2010 on Insidermedicine.com.

 

Transcript of this video
Research Reference for this Video

If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017

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Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected

Dr. Patrick Tchou and Dr. Bryan Baranowski, cardiologists from the Cleveland Clinic describe the catheter ablation procedure for the treatment of atrial fibrillation (A-Fib), what it is, how it’s done and what results can be expected from this surgery.

Excellent animations: showing A-Fib’s chaotic signals, and the pattern of ablation scars around the openings to the pulmonary veins. By the Cleveland Clinic (4:00 min.)

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select. 

If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017

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Video: Inside the EP Lab with Dr. James Ong: Using Mapping & CT Scan Technologies During a Pulmonary Vein Isolation

Cardiac Electrophysiologist Dr. James Ong begins with a brief tour of the EP lab and control room; Dr. Ong explains how pulmonary vein isolation is done with radiofrequency ablation to cure atrial fibrillation.

Included are: Mapping technology; the Virtual Geometrical shell of the heart displayed next to the CT scan; Placement of the catheter, real time tracking; the Complex Fractionated Electrogram (CFE) Map used to identify and eliminate the extra drivers (aside from the pulmonary veins). (6:01) From a series of videos by Dr. Ong, Heart Rhythm Specialists of Southern California.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.


If you find any errors on this page, 
email us. Y Last updated: Saturday, February 18, 2017

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FAQs Coping With Your Atrial Fibrillation: Day-to-Day Issues

FAQs A-Fib afibFAQs Coping With Your Atrial Fibrillation: Day-to-Day Issues

Coping with your Atrial Fibrillation means a patient and their family have many and varied questions. Here are answers to the most frequently asked questions about dealing with the day-to-day issues of having Atrial Fibrillation. (Click on the question to jump to the answer.)

1.  Specialist: “I like my cardiologist, but he has not talked about me seeing an Electrophysiologist [heart rhythm specialist]. Should I ask for a second opinion?”

2. Forewarning? Is there any way to predict when I’m going to have an A-Fib attack?”

3.  Exercise: Can I damage my heart if I exercise in A-Fib? Should I exercise when in A-Fib or skip it and rest?”

4.  Progression of A-Fib: How long do I have before my A-Fib goes into chronic or permanent A-Fib? I know it’s harder to cure. My A-Fib episodes seem to be getting longer and more frequent.”

5.  A-Flutter:They want to do an Atrial Flutter-only ablation, will that help if I possibly have A-Fib as well?”

6.  Medical Marijuana:Is smoking medical marijuana or using Marinol going to trigger or cause A-Fib? Will it help my A-Fib?

7.  Action Plan: During an A-Fib episode, when should I call paramedics (911 in the US) and/or take my husband to the hospital? I’m petrified. I need a plan.”

Related Question:When my husband has an Atrial Fibrillation episode, what can I do for him? How can I be supportive?”

Related Question: In case I have a stroke, what does my family need to know to help me? (I’m already on a blood thinner.)  What can I do to improve my odds of surviving it?”

8.  PVC/PACs:I have a lot of extra beats and palpitations (PVCs or PACs). They seem to proceed an A-Fib attack. What can or should I do about them?”

9.  DIY Monitors:What kind of monitors are available for atrial fibrillation? Is there any way to tell how often I get A-Fib or how long the episodes last?”

Related Question:My mom is 94 with A-Fib. Are there consumer heart rate monitors she can wear to alert me at work if her heart rate exceeds a certain number?”

10.  Heart Rate:Can I have A-Fib when my heart rate stays between 50-60 BPM? My doctor tells me I have A-Fib, but I don’t always have a rapid heart rate.”

Related Question:  “My doctor says I need a pacemaker because my heart rate is too slow. I’m an athlete with A-Fib and have a naturally slow heart rate.”

11.  Circulation:Can I improve my circulation, without having to undergo a Catheter Ablation or Surgery? I’m in Chronic A-Fib. ”

12.  Hereditary A-Fib: Both my uncles and my Dad have Atrial Fibrillation. I’m worried. How can I avoid developing A-Fib? Can dietary changes help? Or lifestyle changes?”

13.  Treatment choices: “How do I know which is the best A-Fib treatment option for me?”

Related Question:In one of your articles it said that having an ablation was better than living in A-Fib. If your article means all types of A-Fib [including Paroxysmal], then I will consider an ablation.”

If you find any errors on this page, email us. Y Last updated: Monday, February 13, 2017
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2017 AF Symposium Video Streaming: Ablation using CardioFocus Laser Balloon

2017 AF Symposium

Live Case: Ablation using CardioFocus Laser Balloon

Video clip: :16 sec view of pulmonary view opening during ablation with HeartLight System; from ‘Ablate What You See & See What You Ablate’.

Video streaming from Na Homolce Hospital in Prague, The Czech Republic. Drs. Peter Neuzil, Jan Petru and Jan Skoda, in their second live case, did an ablation using the CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon (FDA approved April 4, 2016).

Direct Visualization

The doctors showed how they could directly see the Pulmonary Vein opening they were ablating (unlike RF and CryoBalloon systems).

The center of the catheter has an endoscopic (looking inside) camera. (To me, this is a major advantage and ground-breaking improvement for patients.) (Watch :13 video clip)

Laser Energy For Ablation

CardioFocus HeartLight Laser Balloon at A-Fib.com

CardioFocus HeartLight Laser Balloon

In the center of the catheter is an optical fiber which produces an arc of laser (near infrared) energy. When they applied this laser energy, it looked like a green flashing light that circled the PV.

The doctors said that watching this circulating green arc allowed them to visually see if they were making complete circular lesions of the PV.

They later used a regular Lasso catheter to check for ablation integrity.

Variable Diameter Compliant Balloon

The doctors also showed how the CardioFocus HeartLight system uses a variable diameter compliant balloon which can be sized to fit into a wide range of PV openings.

See our library of videos about Atrial Fibrillation

One preliminary research article suggested that the Laser Balloon system clinical outcomes were an improvement over CryoBalloon ablation. 

VIDEO ANIMATION: For a one-minute animation of how the CardioFocus HeartLight system works, see Visually Guided Ablation.

Editor’s Comments:
The CardioFocus HeartLight Laser Balloon catheter seems like a major advance in the treatment of A-Fib, To be able to look directly at the PV opening instead of using fluoroscopy, etc. should make an EP’s ablation task much easier and potentially more effective. And having a variable diameter compliant balloon is an added plus.
But when I talked with the CardioFocus rep at the AF Symposium exhibit hall, he said they were in the process of rolling out the Laser Balloon system to various centers. It may be a short while till the system is up and operational nationwide in the U.S. (It’s already in use in Europe.) We will try to list which centers use the Laser Balloon system.
If real world experience proves its effectiveness, the CardioFocus HeartLight Laser Balloon system may eventually make CryoBalloon ablation a secondary player.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Sunday, February 12, 2017

Resources for this article

FAQs A-Fib Treatments: Medicines and Drug Therapies

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Drug Therapies for Atrial Fibrillation

Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. “ I have a heart condition. Which medications are best to control my Atrial Fibrillation?” What medications work best for me?“

2. HRT: “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?”

3. Rate Control Drug: “I take atenolol, a beta-blocker. Will it stop my A-Fib.”

Antiarrhythmic Drugs

1. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?” (“Pill-In-The-Pocket” makes use of an antiarrhythmic drug such as flecainide)

2. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

3. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

4. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.”

Blood Thinners/Anticoagulants

Note: August 2015 Update: Aspirin is no longer recommended as first-line therapy to prevent A-Fib stroke.

1. “Are anticoagulants and blood thinners the same thing? How do they thin the blood?

2. Should everyone who has A-Fib be on a blood thinner like warfarin (brand name: Coumadin)?”

3. Which is the better to prevent stroke—warfarin (Coumadin), an NOAC or aspirin?

4. “I am on Coumadin (warfarin). Do I now need to avoid foods with Vitamin K which would interfere with its blood thinning effects?”

5. Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”

6. “I’m worried about having to take the blood thinner warfarin. If I cut myself, do I risk bleeding to death?

Related question: My new cardiologist wants me to switch from Pradaxa to Eliquis. if bleeding occurs, is Eliquis easier to deal with?

Related question: My heart doctor wants me to take Xarelto. I am concerned about the side effects which can involve death. What else can I do?”

7. “I”ve read about a new anticoagulant, edoxaban (brand names: Lixiana, Savaysa) as an alternative to warfarin (Coumadin). For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?”

Post-Procedure

1. I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of. Is there anything I can do to get off of blood thinners?“

2. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?“

A-Fib Stroke Risk

1. “What are my chances of getting an A-Fib stroke?

2. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?“

3. “How long do I have to be in A-Fib before I develop a clot and have a stroke?

4. “Is there a way to get off blood thinners all together? I hate taking Coumadin. I know I’m at risk of an A-Fib stroke.”

If you find any errors on this page, email us. Y Last updated: Tuesday, February 14, 2017
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FAQs A-Fib Treatments: Catheter Ablation Procedures

Catheter ablation illustration at A-Fib.com

Catheter ablation

Atrial Fibrillation patients seeking a cure and relief from their symptoms often have many questions about catheter ablation procedures. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer)

1. Heart Function: “Does this burning and scarring during the ablation procedure affect how the heart functions? Should athletes, for example, be concerned that their heart won’t function as well after an ablation?”

Related question: “I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.”

2. Radiation: “How dangerous is the fluoroscopy radiation during an ablation? I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib—A-Fib destroys my life. I’m worried about radiation exposure.”

3. Condition of Heart: “What is an enlarged heart? Does it cause A-Fib? I was told I can’t have a catheter ablation because I have an enlarged heart. Why is that?”

Related question: I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?”

Related question:  I have a defective Mitral Valve. Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?”

4. Age: “I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?”

Related question:I’m 80 and have been in Chronic (persistent/permanent) A-Fib for 3 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation?

5. Blanking Period: “How long before you know a Pulmonary Vein Ablation procedure is a success? I just had a PVA(I). I’ve got bruising on my leg, my chest hurts, and I have a fever at night. I still don’t feel quite right. Is this normal?”

Related question: Since my ablation, my A-Fib feels worse and is more frequent than before, though I do seem to be improving each week. My doctor said I shouldn’t worry, that this is normal. Is my ablation a failure?”

6. O.R. Report: I want to read exactly what was done during my Pulmonary Vein Ablation. Where can I get the specifics? What records are kept?”

7. Procedure Length: “What is the typical length of a catheter ablation today versus when you had your catheter ablation in 1998 in Bordeaux, France? What makes it possible?”

8. Clots/Blood Thinners: “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin, an NOAC or aspirin?”

Related question: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?”

Related question: During an ablation, how much danger is there of developing a clot? What are the odds? How can these clots be prevented?”

9. Exercise: “I’m having a PVA and I love to exercise. Everything I read says ‘You can resume normal activity in a few days.’ Can I return to what’s ‘normal’ exercise for me?”

10. Non-PV Triggers: “Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots? I had a successful catheter ablation and feel great. Could they eventually be turned on and put me back into A-Fib?

11. Heart Rate: “I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

12. The Bordeaux Group: “I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?”

13. Cure? “I have Chronic Atrial Fibrillation. Am I a candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?”

Related question: I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a ‘cure’. If I take meds like flecainide which stop all A-Fib symptoms and have no significant side effects, isn’t that a ‘cure?’”

14. Tech Advances: “I’m getting by with my Atrial Fibrillation. With the recent improvements in Pulmonary Vein ablation techniques, should I wait until a better technique is developed?”

If you find any errors on this page, email us. Y Last updated: Tuesday, February 14, 2017
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