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Testing

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

AF Symposium 2015

Sébastien Knecht PMD PhD

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

By Steve s. Ryan, PhD, July 2015

Pr. Sebastian Knecht from CHU Brugmann, Brussels, (now AZ Sint Jan, Brugge), Belgium gave a presentation entitled “AFACART Trial—Design and Preliminary Results.” (AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI).

Introduction

In preparation for their ablation the patient dons the ECGI vest-like device. The data generated creates an image of the heart and pinpoints sites (“drivers”) producing A-Fib signals. This 3-D computer model of the patient’s heart is used during the ablation procedure.

AFACART Clinical Trial Design and Participants

The AFACART trial is a European multicenter, feasibility, non-randomized study using “Panoramic Electrographic Non-Invasive Mapping”, specifically the CardioInsight—ECVUE System, for ablation of persistent A-Fib. 

AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI

Ablation patients are to be followed for 12 months. The effectiveness of Panoramic Electrographic Non-Invasive Mapping is to be compared to conventional mapping and ablation procedures.

Eight European centers in France, Belgium and Germany are participating in this clinical trial. None of these centers had any practical experience with this system before this study.

Ablation Steps One to Three

In an important change to standard ablation procedures, the first step in the ECGI/ECVUE ablation process is ablation of A-Fib drivers (rotors and foci).  (This is in comparison to the step-wise approach that begins with ablation of the pulmonary vein openings.)

If A-Fib doesn’t terminate to sinus rhythm or stable atrial tachycardia isn’t achieved (> 5 min), then a standard PVI is performed.

This is followed by linear lesions. And finally by Electrocardioversion.

AFACART Trial Preliminary Results

• Step One (driver ablation only): 64% of the persistent A-Fib patients had their A-Fib terminated.
• Step Two (driver and PVI ablation): 66% termination
• Step Three (driver, PVI, and LA linear lesions) 73% termination

For our technical readers, Dr. Knecht defined ‘drivers’ as “local reentrant circuits (> 1.5 rotations) or focal breakthroughs (>2) that appear at the same spatial location per window.”

In 94% of patients, driver ablation had a significant impact on the A-Fib termination process. A-Fib cycle length was prolonged in all persistent patients except for 6%. Even patients who were not terminated (27%) had their A-Fib cycle length prolonged by driver ablation.

After 12 months, 72% of patients were A-Fib free and no longer taking antiarrhythmic meds (AADs). 31% had Atrial Tachycardia recurrence, but many had a second ablation.

Overall 83% were A-Fib free, 17% had Atrial Tachycardias and only 9% were still in A-Fib.

Ablation procedure time averaged only 44.7 minutes. As the number of driver regions increased, the ablation success rate decreased. 66% of drivers were in the Left Atrium, 34% in the right. 70% of termination sites were in the left atrium, 30% in the right.

Driver Sites and CFAEs

• In these persistent A-Fib patients, 50% of both atria had CFAEs.
• Most (but not all) driver sites contained CFAEs.
• Successful driver ablation only ablated 19% of both atria (this is a major improvement and resulted in much less ablation damage to the heart compared to trying to ablate all CFAE areas).

Dr. Knecht stated that “use of the ECVUE system seems to result in a more specific selection of CFAEs leading to a more targeted ablation strategy.”

Dr. Knecht’s Conclusions

Ablation of A-Fib drivers is associated with a high rate of A-Fib termination.

• Drivers are distributed in both atria (2/3 LA and 1/3 RA).
• Results are reproducible among centers without prior practical experience with the system.
• Preliminary chronic results are very promising.

Editor’s Comments:
Driver Ablation More Important Than PVI in Persistent A-Fib: ECGI is changing the way ablations are done and our understanding of A-Fib. In persistent A-Fib, the mapping and ablation of drivers is more important and is done before a PVI ablation. While driver ablation had a 64% success rate, doing a standard PVI after driver ablation only improved results by 2%.
ECGI/ECVUE Major Improvement in Ablation Success Rate: An 83% success rate after 12 months following ablations for tachycardias, is a major improvement and source of hope for persistent A-Fib patients. These results were even better when one considers that only 9% were still in A-Fib.
ECGI/ECVUE Results in Much Fewer Ablation Burns: Previous protocols for ablating persistent A-Fib usually involved mapping and ablating CFAEs. But CFAEs in persistent A-Fib patients can cover 50% of the atria surfaces which often necessitated a lot of burns and debulking.
Too many ablation burns could result in the development of fibrosis (dead heart tissue where the ablation catheter produced burns and scarring) and a stiffening of the atria with loss of pumping ability. ECGI/ECVUE only requires ablating 19% of the CFAE areas resulting in much less lasting damage to heart tissue.
Driver Ablation Prolongs A-Fib Cycle Length: Driver ablation had a major effect on the A-Fib termination process. A-Fib cycle length was prolonged in all but 6% of the persistent A-Fib patients. This is perhaps a first step in improving outcomes for persistent A-Fib patients.
Reproducibility: The most important finding of Dr. Knecht’s report is that ECGI/ECVUE works in other centers without doctors (operators) having to undergo extensive training.
These preliminary results from this multi-center clinical trial are quite impressive for the treatment of patients with persistent A-Fib. Hopefully it won’t be long before the ECGI/ECVUE system is available in more countries. (ECGI was invented at Washington Un. in St. Louis, MO and is available there on a limited basis.)

To learn more about ECGI, see Non-Invasive Electrocardiographic Imaging (ECGI): Presentation Summary and Comments from the 2013 AF Symposium. You may want to read this report in conjunction with Dr. Haissaguerre’s 2015 AF Symposium presentation The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques.

References for this article

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Last updated: Friday, January 1, 2016

Persistent A-Fib: ECGI Insights to Finding Additional Drivers by Dr Jais

AF Symposium 2015

Pierre Jais MD

Pierre Jais MD

Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions

By Steve s. Ryan, PhD, July 2015

Dr. Pierre Jais of the French Bordeaux/LIRYC group gave a presentation on “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”

He described a study of the ablation of 50 persistent A-Fib patients using ECGI to map and ablate A-Fib signal drivers.

A-Fib was terminated in 79% of patients, with 10% returned to sinus rhythm and the remaining 69% in tachycardias (but with no A-Fib).

For those still in arrhythmia, ECGI was used to map, analyze and diagnose the locations of the arrhythmias signals, and additional ablation lesions were performed. Identified were 25 macro-reentry circuits and 14 focal/localized-reentry circuits.

The reentry circuits found by ECGI were:

• common atrial flutter in 14 patients
• perimitral flutter in 9 patients
• roof dependent flutter in 2 patients

Dr. Jais showed many slides and videos of how ECGI mapped and analyzed where these arrhythmias were coming from and how they were ablated.

Dr. Jais’ Conclusions

Dr. Jais stated that the study data revealed, “the focal/localized-reentry were adjacent to drivers at 0.9cm from the core of driver with low voltage (0.5 mV)”.

To clarify, this means that the drivers of the remaining arrhythmias were located very close (adjacent) to the drivers previously mapped by ECGI.

Therefore, when ECGI locates an area of rotors and drivers, it is highly likely this is where the source of additional arrhythmias will most likely be found. This insight reduces or eliminates the need (and time) to search other areas of the heart thereby shortening procedure length and decreasing the number of lesions needed.

Editor’s Comments:
ECGI mapping and ablating is changing our understanding of and our techniques for ablating persistent A-Fib. If a patient has continued arrhythmias after the initial ablation, ECGI often can re-map and identify where the remaining arrhythmias are coming from, usually very near previously identified driver locations. This is a valuable insight for doctors doing ablations.
For patients, it may mean a shorter procedure time with fewer burns needed to eliminate the sources of A-Fib signals.

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Last updated: Thursday, August 6, 2015

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

AF Symposium 2015

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

By Steve S. Ryan, May 2015

ECGI is changing everything—not only the way mapping and ablations are done, but also our basic understanding of A-Fib. Instead of potentials and CFAEs, EPs will focus on ablating drivers (rotors and foci). Ablating the PVs will still be basic. But in more difficult cases, EPs must look for non-PV triggers or drivers.

Prof. Michel Haïssaguerre of the French Bordeaux group/LIRYC gave a presentation entitled “Beyond PVI—Mapping and Ablation Techniques for Elimination of Drivers in Persistent AF.” Non-Invasive Electrocardiographic Imaging, or ECGI (from CardioInsight) is a radically new and innovative mapping and ablation system.

The ECGI Vest-Like Device Innovative Mapping and Ablation System

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

The day before their ablation, the patient lies down on their back and a technician places a vest-like device with 256 electrodes over their chest and stomach. These electrodes combine with rapid CT (Computed Tomography) scans to produce a very detailed 3D color map of the heart.

The system automatically detects rotors and foci and computes them into a “Cumulative Map” or movie. These driver regions are ranked, based on statistical prevalence. They are displayed in statistical density maps which define the ablation roadmap.

The use of ECGI mapping results in a drastic decrease of RF burns needed

The ECGI vest doesn’t directly record A-Fib signals from the septal regions. But Dr. Haïssaguerre showed slides where the septal drivers project onto the anterior and posterior attachments of the septum and are thus able to be mapped. For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging (ECGI).

Ablation using ECGI results in a drastic decrease of RF burns needed to produce A-Fib termination.

In ECGI, Paroxysmal and Persistent A-Fib Ablation are Different

Paroxysmal: Using ECGI in 41 paroxysmal patients, Dr. Haïssaguerre found that the A-Fib drivers originated from the PV/post LA region. They consisted of PV discharges interacting with short-lived ostial rotors, which is in accordance with current knowledge and practice of A-Fib ablation. (A standard PVI ablation normally targets these areas.)

Persistent: But in 248 persistent A-Fib cases (54% with Structural Heart Disease), he found multiple interplaying A-Fib drivers coming from both atria but usually clustered in 4 regions. (The regions could vary from 1-7.) These drivers were short lived (3-4 reentries/firings) but periodically recurred in the same areas. As one would expect, the number of driver regions increased with the duration of persistent A-Fib. Long-Lasting persistent had 7 driver regions diffused throughout the atria. Cases with only 1 driver region were rare (9%).

Relationship of Drivers and CFAEs

These driver regions overlapped with areas of CFAEs (Complex Fractionated Atrial Electrograms). But whereas CFAEs were found in 49% of the total atrial surface, drivers were found only in 19%. Also, fractionated signals were more frequent and spanned a greater part of the A-Fib cycle length in driver regions than elsewhere (71% vs 47%). (This is good news for patients with persistent A-Fib. With ECGI, much less heart area needs to undergo ablation burns.)

Best Ablation Outcome is A-Fib Termination, But Not Always Possible with Persistent A-Fib

Dr. Haïssaguerre showed slides where he ablated driver regions which transformed rapid complex A-Fib signals into slower organized signals. He stated from his own experience and from several studies that the best outcome of ablation was A-Fib termination into sinus rhythm or tachycardia.

But this result was much harder to achieve in long-lasting persistent A-Fib. In cases where patients had only recently went into persistent A-Fib (1-3 months), 75% had A-Fib termination targeting driver regions. While in long-lasting persistent A-Fib, only 13% had A-Fib termination. Dr. Haïssaguerre’s hypothesis was that early persistent A-Fib is initially driver-dependent, while long-lasting persistent cases progress to widespread substrate disease.

In another study following 90 patients, 85% of patients with A-Fib termination were A-Fib free after 12 months (in the remaining 15%, 54% were paroxysmal). While patients who didn’t have their A-Fib terminated, only 63% were A-Fib free (all were persistent).

What EPs Do When AF Persists After ECGI Driver Ablation

• Check driver regions (including PVs) to ensure abolition of rapid-disorganized EGMs (electrogram signals).

• Body Surface Remapping—to look for new drivers appearing after the first ones are eliminated. Many have observed that this strategy often improves results in difficult cases of long-lasting A-Fib.

Right Atrium Ablation

Dr. Haïssaguerre recommended ablating the right atrium after the left. Right atrium drivers can disappear after left atrium ablation.

Dr. Haïssaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers which are Multiple, Meandering, ShortLasting and Associated with Complex EGMs (electrogram signals).

• Ablation targeting these AF critical regions allows high rate of AF termination with minimal RF delivery.

• 85% AF freedom at one year when procedural AF termination is achieved.

• Reproducibility in 8 centers in Germany, Belgium and France (AFACART) (Eight centers in Europe are now performing ECGI ablations with similar results.)

Editor’s Comments:
Non-PV Triggers: If your EP only ablates the PVs, you should look elsewhere. I just read an O.R. (Operating Report) where the EP only CryoBalloon ablated the PVs. Even though the patient was still in A-Fib after the PVs were ablated, the EP didn’t look for non-PV triggers. He simply shocked the patient back into sinus rhythm and put him on an antiarrhythmic drug. Chances are the patient’s A-Fib will return, since the non-PV triggers in his heart weren’t ablated.
Driver regions overlap with CFAEs—CFAEs can be ignored: In difficult cases of A-Fib, EPs used to spend a lot of time mapping and ablating CFAEs. Sometimes there were so many CFAEs that the EP wound up debulking much of the left atrium. In Dr. Haïssaguerre’s research, CFAEs could cover nearly half of the total atria surface. But with ECGI, only 19% of that area is ablated. ECGI makes the EP’s job simpler and causes less burns on the patient’s heart.
Try to Get Out of Persistent A-Fib: If you haven’t done so already, ask your EP to be Electrocardioverted in order to avoid long-lasting A-Fib which causes atrial remodeling that produces widespread fibrosis and diffuse driver regions.
You may want to try the newer antiarrhythmic drug Tikosyn (dofetilide) which works well in some cases of persistent A-Fib. (When starting Tikosyn, you will have to be hospitalized for three days to get the dosage right and to check for bad side effects.)
Currently some long-standing A-Fib can’t be cured: The best outcome of ablation is A-Fib termination. But some long-lasting persistent cases turn into widespread substrate disease where it’s not always possible to map and ablate drivers. Even the famed Bordeaux group hasn’t yet figured out a way to achieve 100% success when ablating all long-standing persistent A-Fib.
If you have long-standing persistent A-Fib, should you just throw in the towel and give up? No. In Dr. Haïssaguerre experience, 63% of persistent patients who didn’t have their A-Fib terminated were still A-Fib free. You could be in that 63%. Just be realistic and don’t expect miracles.

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Last updated: Saturday, May 30, 2015

DIY Heart Rate Monitors: How They Work For A-Fib Patients (Part II)

Polar Heart Rate Monitors

Go to: DIY Heart Rate Monitors

by Steve S. Ryan, PhD, Updated April 2015

A-Fib patients sometimes use consumer ‘DIY” Heart Rate Monitors (HRM) when exercising or performing physically demanding activities (For specific models and options, see our article, DIY Heart Rate Monitors & Handheld ECG Monitors Part I.)

How Do DIY Heart Rate Monitors Work?

Basic HRMs use a chest strap to pick up the electrical signals from the heart. However, due to the inherent design of the chest strap, the accuracy is somewhat limited and is no replacement for the signals recorded by a Holter or Event Monitor.

Heart-Rhythm-Monitors-EKG - 325 pix wide at 96 resA HRM keeps track of your heart’s R-R interval or the time between R peaks. Without getting too technical, the R peak on a generic ECG waveform (see the diagram) corresponds to the ventricle beat (depolarization) and has the largest amplitude (height) of the complete waveform.

When the amplitude (picked up as a voltage differential) exceeds a certain threshold, a “beat” is picked up by the chest strap and transmitted wirelessly to the HRM. It is the time between these R peak “beats” that is used by the HRM to determine instantaneous heart rate. It is only going to pick up episodes of arrhythmia as are manifested in ventricle beats (the R on the waveform).

Learn more about the EKG signal, see Steve’s article: Understanding the EKG (ECG) Signal.

So if your arrhythmia manifests itself in funky R activity (higher than normal rate) you will see a corresponding readout on the HRM. In this same light, an irregular or unevenly spaced R peaks will not be picked up by the HRM.

This is one of the fundamental differences in how data is recorded by HRMs (R-R interval) versus Holter/Event Monitors (actual waveform).

In fact, this is what Polar has to say:

Polar products are not designed to detect arrhythmia or irregular rhythms and will interpret them as noise or interference. The computer in the wrist unit will make error corrections, so that arrhythmia beats are not included in the averaged beats per minute. The blinking heart symbol in the face of the unit, however, will continue to show all heart beats received.

In most cases the Polar products will work fine for persons with arrhythmia.

Example PC interface capability of a Polar PC program.

Graphic example PC interface capability of a Polar PC program.

HRM Recording Capability

Most HRMs provide some internal storage recording capability. While lower cost HRMs simply record low, high and average heart rate, upper end models allow you to download heart rate data to your PC.

App-enabled smartphones are changing how this data is viewed, collected and saved for future review.

How To Setup and Use an HRM

On most of the HRMs, you can set a heart rate zone, and the watch monitor (or app-enabled smartphone) will record how long you stayed in that zone.

You could then program a high heart rate zone which you might only enter if you were in A-Fib. That way you could record how long you stayed in A-Fib and what your max heart rate was. This data could be reviewed on the watch monitor (or app-enabled smartphone) without having to download it to a PC.

On HRMs with PC interface capability, you can view data in a graphic form (on some watches/smartphones you can view the graphic data but with lower resolution.) This analyses could tell you when you were at a higher heart rate—A-Fib—and how long you stayed there. Of course these kinds of features require some PC skills, but typically the programs are pretty user friendly. (See the above graphic example of a Polar PC program).

For more, see our article, DIY Heart Rate Monitors & Handheld ECG Monitors.

Shop Amazon.com for Heart Rate Monitors & Handheld ECG monitors for A-Fib Patients. When you use this link, your purchases generate a small commission (at no extra cost to you) which we apply to the maintenance costs of A-Fib.com. Help A-Fib.com become Self-Supporting!

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Last updated: Tuesday, April 14, 2015

Consumer Handheld ECG Monitors

by Steve S. Ryan, PhD, April 2015

This category of consumer monitors has been growing of late. Going beyond just monitoring your heart rate and plus, these units capture data and display it as an ECG (EKG) in real time.

AliveCor AC-009-UA-A Heart Monitor by AliveCorAliveCor with logo

Detects A-Fib. Attaches to the back of your iPhone; ECG is obtained by holding the iPhone and placing at least 1 finger from each hand on the electrodes embedded into the back of the phone case.

Your data is accessible through the AliveECG app, also stored on secure, encrypted servers, so you can view them anywhere and share them with your doctor.

Newest model is 3rd generation (Doctor prescription no longer required).”

The HeartCheck™ PEN handheld ECG device from CardioComm Solutions

Heart Check Pen

The HeartCheck™ PEN handheld ECG device from CardioComm Solutions

The HeartCheck™ PEN handheld ECG device is the only device of its kind cleared by the FDA for consumer use. No prescripton required. (There is second device that does require a prescription to order it, the HeartCheck™ ECG Handheld Monitor.)

The pocket-sized PEN allows you to take heart readings from anywhere, the moment symptoms appear. Then using the USB cable provided, connect the device to your PC and run ‘GEMS™ Home’ program to upload your heart rhythm files containing your ECGs and send it to a physician or ECG Coordinating Center (for a fee). The  ECG Coordinating Center or physician will create an ECG report on your heart analysis identifying any potential issues. The report will be made available on your PC through the GEMS™ Home program.

There’s a good review of the Heart Check pen by  over at LivingWithAtrialFibrillation.com (posted Sept. 2013). Robert goes into great detail about how to “unlock” your device to you can see the actual reading, the costs of reports (the first one is free), and the details about how all this works. There’s even a $20 off discount code if you order from the manufacturer’s website. There’s also a video at:  http://www.theheartcheck.com/products/

Keep in mind that the HeartCheck™ PEN reports aren’t meant to be used for diagnosis in an emergency. Reviews on Amazon.com are mixed, but it may work for you. Read one or both of the reviews mentioned above.

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Handheld ECG Monitor CMS-80A from FaceLake (or Contec)

Facelake Hand-Held Single Channel ECG, ECG 80A Link

Facelake Hand-Held ECG 80A (Helps support A-Fib.com)

Note: Read about how Tom Burt used the CMS-80A in his Personal Experience story. He writes, “This came in very handy as a way to inform my EP when I did get out of rhythm. This was done by faxing him a strip of the printout.”

The CMS-80A is a single channel, 12 lead monitor which can provide data via one of three ways: on the unit display, via the thermal printer internal to the unit or via a USB connection to a PC. The printout from the unit offers the easiest and most accurate means to view lead output. While you can view lead output on the display, you will find that it is not to the same level of detail as the printout.

Like most normal ECG monitors, 10 electrodes are attached to the body as follows: 6 suction cup leads to the chest and 4 alligator clip leads to the arms and legs. The unit does not rely on the normal press-on style contacts but rather takes a simpler approach with its reusable contacts. Personally, I [Ed Webb] wasn’t too impressed with the suction cup style contacts as they feel funny and leave a mark as if you had been attacked by an octopus. But they seemed to do the job. The alligator clips, while funky, were quick and easy to attach.

The waveforms presented are not what you would expect from an ECG in your cardiologist’s office, but they can provide the simple basics to make a quick determination whether you are in A-Fib. In particular, by examining the output from Lead II, or perhaps Lead aVF, you can quickly observe the absence of a P wave—one sign that you may be in A-Fib. Additionally, examining R-R intervals and whether they are uniformly spaced can be another means to aid in that determination.

Facelake Hand-Held Single Channel ECG, ECG 80A Link

Facelake Hand-Held ECG 80A

From a practical perspective, it could be that you choose to only attach the alligator leads to your arms and legs and forego using the chest leads. You will obviously not have the data from the chest leads (V1 to V6), but that information may not be needed for A-Fib purposes.

Note: This unit does not require a prescription from your doctor. For more info and to see what the display looks like, use this link to go to Facelake.com. The CMS-80A (ECG-80A) can be purchased directly from Facelake.com and (using our portal link) from Amazon.com.

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 In-Depth Report Of ECG Monitors

For an extensive evaluation of the above three hand-held ECG monitor with multiple photos and scans see James Grier’s Comparison of Handheld, 1-Lead/Channel ECG/EKG Recorders” at  http://www.ndsu.edu/pubweb/~grier/Comparison-handheld-ECG-EKG.html

Report: Comparison of Handheld, 1-lead/Channel ECG/EKG Recorders

I’m pleased to share a great resource for anyone considering one of the newer hand-held ECG monitors. Comparison of handheld, 1-lead/channel ECG / EKG recordersby James W. Grier, Emeritus Professor of Biological Sciences, North Dakota State University. This report is extremely detailed and extensive (and was last updated March 19, 2014).

He tests and compares eleven units, includes multiple photos of each step of testing and multiple print outs of the results. (Jim’s first report was posted in 2006 and has been updated in 2008, 2013, and in March 2014).

It’s the most thorough report on the topic you will find anywhere. (BTW: We hope to get Jim to write an article or two for A-Fib.com about his own A-Fib. (He’s also involved with an upcoming A-Fib medical study about scuba diving that’s being developed by the dive-medical organization, Divers Alert Network, or DAN.)

Jim Grier’s report,Comparison of handheld, 1-lead/channel ECG / EKG recorders includes the three monitors we discuss below. Go to http://www.ndsu.edu/pubweb/~grier/Comparison-handheld-ECG-EKG.html

Amazon button with glowHelp A-Fib.com become Self-Supporting! Use our ‘portal’ link to Amazon.com. When you do, your purchases generate a small commission (at no extra cost to you) which we apply to the maintenance costs of A-Fib.com. Bookmark this link for future purchases. Go to Amazon.com using A-Fib.com’s ‘portal link

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Last updated: Friday, January 1, 2016

The Virtual Heart Computerized Simulation – Dr. Natalia Trayanova

AF Symposium 2015

Dr. Natalia Trayanova, Johns Hopkins University

Dr. Natalia Trayanova

The Virtual Heart Computerized Simulation

by Steve S. Ryan, PhD

The most hopeful, promising research of the 2015 AF Symposium was presented by Dr. Natalia Trayanova of Johns Hopkins Un., Baltimore, MD. She described the “virtual heart”—a computerized model to simulate an individual patient’s heart.

A Computerized Model

The idea is to build computerized models that can be used to guide an individual patient’s therapy. She previously simulated a heart attack in a specific region of an individual heart and how it affected the dynamics of that specific heart.

Using the virtual heart computerized simulation, she can, for example, program in not only how much fibrosis an individual heart has but its structure. (Is the fibrosis circularly-distributed? Does it have a complex shape or is it patchy?)

The Bordeaux Group Patient Data

Dr. Trayanova is rapidly developing more atria data and experience. The Bordeaux group is providing her patient data from their ECGI body surface potential mapping system (CardioInsight). She has done approximately a dozen retrospective studies using the virtual heart technology (as of January 2015).

The Virtual Heart Simulation images

The Virtual Heart Simulation images

How it Works

Dr. Trayanova and her team start by doing an MRI scan. Then they hyper-enhance segments which correspond to areas of fibrotic remodeling.

The next step is to develop a computational mesh that incorporates representations of ion channels, calcium cycling and other electrophysical aspects of an individual’s atria. All this is incorparated into patient-specific geometry of the model.

What the Model Can Reveal

Then they let the model run and see what the arrhythmia looks like. Does the fibrotic substrate anchor rotors in particular locations? What are the spatial characteristics of the regions where they are located? Can these spatial metrics guide where the proper ablation should be?

Dr. Trayanova’s team merges these virtual atria with a CARTO map to predict where the catheter should ablate.

Editor’s Comments:
The potential of Dr. Trayanova’s research for A-Fib patients is incredible! Imagine getting an MRI and knowing where your A-Fib is coming from, how your A-Fib affects and works in your heart both now and in the predictive future, how various A-Fib drugs can be expected and predicted to affect your heart, how much and what kind of fibrosis you have, how you can expect your fibrosis to progress and affect you over time, what therapies should be done in your particular case, if you need a catheter ablation, where exactly in your heart the EP needs to ablate, and to be able to accurately predict whether or not or how fast you will progress from paroxysmal to persistent A-Fib based on computer models that mirror your own heart.
Dr. Trayanova’s research has the potential to radically change the way A-Fib is treated. Almost all the uncertainties EPs and A-Fib patients now have to deal with can potentially be eliminated with the virtual computer reconstruction of individual A-Fib hearts.
References for this article

Return to 2015 AF Symposium: News and Views

Return to 2015 AF Symposiums: Indepth Reports for Written for Patients

Last updated: Thursday, April 16, 2015

Dr. Carlo Romero A-Fib Patient Story

Dr Carlo Romero from The Philippines

Dr Carlo Romero
from The Philippines

A-Fib Patient Story #79

Philippino Dr. with A-Fib Has Amiodarone Problems—Then ECGI & Ablation at Bordeaux

By Dr. Carlo Romero, The Philippines, February 2015

I am a 49-year-old male from the Philippines. I was diagnosed with A-Fib in 2007 at age 42. It happened after I was dehydrated playing golf. The A-Fib resolved by itself after a few hours. But after a few months, I had another attack. When I went to the ER, an ECG documented the AFIB. I was not given any medication but was advised to stay away from triggers which I did. I even stayed away from cigarettes, drinking, chocolates, food with monosodium glutamate.

After Three Years, Severe Pain Triggers A-Fib—Amiodarone Works, But Thyroid Problems

 I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone.

I had no known A-Fib attacks for three years until I was operated on for a herniated disc in 2010. The severe pain and the medications probably triggered the A-Fib again as I had several attacks. I was referred to an electrophysiologist in Manila which is an hour and half plane ride from our province. This time I was given amiodarone and Coumadin. I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone. I was shifted to 100mg flecainide bid which again limited my A-Fib to probably one attack per year.

A-Fib Attacks Become More Frequent—Decides To Go To Bordeaux

At this time I was already doing research about what other options were available, because I know that in time, the medications will stop working. In 2010, I was already in touch with Steve Ryan and had already heard of ablation. I had written several big centers and inquired about ablation procedures and cost. I wrote emails to Bordeaux and to the secretary of Dr. Natale. But since the attacks were few and far between, I decided to stick to medication which controlled the symptoms.

 It was a choice between having the ablation in San Francisco or the Bordeaux group…The cost made me decide on Bordeaux, because it cost half that of San Francisco.

However mid-2014, after a bout of flu, the A-Fib symptoms recurred and the attacks became more frequent. I learned that at this time that there was an ablation center here in Manila, but it is still in the infancy stage. So, I decided to go abroad. It was a choice between having the ablation in San Francisco or the Bordeaux group since they have been the most talked about ablationists in the forums. The cost made me decide on Bordeaux, because it cost half that of San Francisco.

Arriving at Bordeaux Hospital

Carlo Romero in Bordeaux hospital room 500 pix at 96 res

Carlo Romero in Bordeaux, France, hospital room

In August 2014, I wrote Bordeaux emails, and they made me answer a questionnaire to determine my status. I sent my reply and was told I would be a good candidate. I was given an ablation date Nov 3, 2014, more than 2 mos. from the time I inquired. I was instructed to do some blood tests and a TEE 2-3 weeks prior to my ablation and to settle the payment for the procedure 1 month before the ablation date. I complied with all of these requirements, got a medical visa from the French Embassy, plane ticket, hotel booking and was all set. I arrived in Bordeaux on Oct 29, 2014. Since we still had time, we first went to Lourdes, France and then back to Bordeaux the next day.

Nov 3, 2014, Monday, I was told to be at the Hospital at 8am. To be sure that we didn’t get lost, we took a cab which cost around 45 euros coming from the center of Bordeaux near the opera house. Admission was a breeze, and I made sure we had internet which you can get in the Admitting section (ask them about it because the nurses are not familiar with it). I made sure of the internet connection to be able to use the app I downloaded which helps me to communicate in French. (Translate App) When you type in English, the app will translate it to French.

I was attached to a holter monitor whose signals were transmitted to the nurse’s station. The first day was spent getting X-rays, lab exams, preparation and shaving of the groin area. They also started injecting heparin. I was told to stop amiodarone 5 days prior to ablation. But since I learned from Steve Ryan that amiodarone has a long half-life, we asked Dr. Jais thru email if the instruction was right. He was able to correct it to 10 days prior to ablation and pradaxa 48 hours prior to ablation.

Ablation with ECGI

Carlo Romero with nurse preparing the ECGI before ablation

Carlo Romero with nurse preparing the ECGI before ablation

The next day, I received IV fluids and was brought down to the CT scan area. I laid down on a bed and was given a vest which I learned later was an ECGI. It’s the new procedure which, according to Dr Haissaguerre, is not yet in use in the US. But they have found it very useful and promising.

His explanation is that it is like an ECG. But instead of 12 leads, it has 252 leads (attached in the vest) The ECGI vest represents the future of the mapping procedure, and according to him will shorten the OR time since they can map out the heart prior to the procedure. (For a further explanation of how the ECGI mapping system works, see “How ECGI [Non-Invasive Electrocardiographic Imaging] Works.”)

I think I was the 2nd case that day since I was brought down at the theatre at 1 pm. I did not see Dr Haissaguerre at that time nor prior to the procedure which made me a little bit anxious. But I was assured by his assistant that He will be doing the ablation. The assistant doctor asked me if it was ok that he start with the insertion of the catheter and that Dr Haissaguerre will be the one doing the ablation later, to which I agreed.

I must have dozed off. Because when I became aware again, I heard that we were about to be finished. Although during the ablation there were instances where I felt my heart going very fast, then they would later massage my neck area. And then after a while, there were two more cycles like that. I was told later that, since I was not in A-Fib, they had to induce me several times. My procedure took almost 4 hours.

After the Ablation—Time With Dr. Haissagguerre

Wednesday, when I woke up, I had a fever of about 39 degrees and had a difficult time breathing. The nurses upon instruction from the doctor gave me paracetamol which lowered the fever, but I was still in pain if I breathed. I was really worried at that time and kept on reminding the nurses to ask the doctor when will they see me so I can talk with them about these symptoms.

That night, a young doctor came to my room with a portable 2d echo and, after examination, concluded I had fluid around my heart and that the fever and the difficulty of breathing were related to that. I was given an anti-inflammatory which relieved the symptoms in 2 days. At this time my abdomen was black and blue due to the round-the-clock injection of heparin. Towards the evening , I was allowed to start with soup and yogurt and later solid foods if I could tolerate them.

Thursday, the fever and the difficulty of breathing diminished. The nurses also advised me to start pradaxa after my last dose of heparin. I was allowed to sit up already and go to the bathroom. In the afternoon, Dr Haissaguerre was able to visit me which was the first time I met him face-to-face. My wife told me that he visited a few hours after my procedure, but I was mostly asleep at that time. He had an aura of confidence in him that made me feel that I was talking to a very knowledgeable person. He explained that I had 3 problematic areas. 1 in the atrial septum and 2 near the pulmonary veins. He added that since I was not in A-Fib, they had to induce it with isoproterenol.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week.

They started with the atrial septum focus which made the A-Fib stop after they had ablated it. But since they knew that I had 3 problematic areas even before the procedure, they induced me again and ablated the 2 remaining areas near the pulmonary veins. After that I was told they could no longer induce my A-Fib.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week. And I was told that I was the first Filipino patient he had. I was also able to meet for the first time Laurence Bayle, the secretary of the doctors with whom I was in contact most of the time. Sometimes it would take a day or two for my emails to be answered, sometimes a week. But despite that, I was able to arrange and carry out my ablation. Probably the volume of the inquiries made it impossible for them to answer immediately.

Dr. Michele Haissagguerre with Dr. Carlo Romero

Dr. Michele Haissagguerre with Dr. Carlo Romero

Discharge—Questions For Dr. Haissaguerre

The next day, Friday, I was told that I would be discharged. I was given all the instructions. While waiting for our Dr Haissaguerre to meet us prior to discharge, we were able to go around the hospital and outside it. From what I understand, it’s a big hospital building which caters solely for heart patients. We were sent to the admitting section to settle our accounts, but we were told that we would have no additional payments, as everything is included in the package.

When Dr. Haissaguerre arrived to see us in the afternoon, I informed him about skipped beats which bothered me post op. He told me that it was normal for an ablated heart to skip beats especially since I had a pericardial effusion, but that they will go away in time. (the skipped beats slowly went away in a month’s time).

I went back to the hospital in November 10, 2014 for my final check-up prior to being allowed to go home. The next few days, we opted to go to Paris and spent some vacation time just in case there was still a need to see Dr. Haissaguerre prior to our flight back home to the Philippines.

Lessons Learned

The whole “healing journey” was very memorable. I cannot believe that I really went out of country just to have the procedure, but everything went as planned. A lot of anxious moments and hesitancy, but I made it through. A few hitches here and there, but nothing that couldn’t be handled.

In this age of the Internet, we as patients have the power to learn more about our disease and act accordingly. We can opt to just live with it which is not really a bad choice as a lot of A-Fib patients have done successfully. Or we can be proactive about it. Of course the ablation procedure is not 100% curative nor 100% safe, But I made my decision based on my goal that I still wanted to practice my profession as a doctor. I owe it to my patients to try to heal myself by the best possible means so that I can render the best medical service to them.

I am now exactly 100 days post ablation. I’m still on anticoagulants, but am A-Fib free. In the last conversation I had with Dr Haissaguerre, I asked him if there are things that I am prohibited to do or food that I am not allowed to eat, and he told me no prohibitions.

“Live a Normal life” and that’s what I plan to do.

Carlo Romero
Email: cadromero1170@yahoo.com

Editor’s Comments:
Because Dr. Carlo had been in A-Fib for some time, his ablation probably was more challenging. It took four hours which was longer than usual considering that the mapping had been done already by the ECGI system. He had a minor pericardial effusion which is often unavoidable in more extensive ablations.
The ablation Dr. Carlo had represents a radical, transformative change in ablation therapy and may alter the way ablations are done. Normal catheter ablation for A-Fib usually starts with isolating the pulmonary vein openings. But Dr. Haissaguerre instead started with the atrial septum area as indicated by the ECGI system. Only later did he go to the pulmonary vein areas. ECGI will certainly change the way catheter ablations are performed.
Dr. Carlo Romero is a great example of a proactive A-Fib patient who educated himself about A-Fib, researched all his options, found the right doctor for him, and wouldn’t settle for less than the opportunity for a complete cure of his A-Fib.

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If you find any errors on this page, email us. Y Last updated: Sunday, July 17, 2016

The Year in Review: Highlights and Achievements

By Steve S. Ryan, PhD

When I think about the field of atrial fibrillation in 2013, several thoughts come to mind. There were technical advancements, some new drug therapies, and additions to our understanding of Atrial Fibrillation (and a few accomplishments for our A-Fib.com website).

Heart Imaging And Mapping Systems

Perhaps the most important technical innovations in 2013 for A-Fib patients were the introduction of two new heart imaging and mapping systems. A third system, the Bioelectronic Catheter, represents a whole new technology with tremendous potential for A-Fib patients.

Patients wearing 'vest' lies down for the ECGI.

The ECGI System

The ECGI system, combined with a CT scan, produces a complete 3-D image of your heart along with identifying all the A-Fib-producing spots. Think of it as an ECG with 256 special high resolution electrodes rather than 12. It greatly reduces your ablation time and your radiation exposure.

A day before your ablation, you simply don a special vest with 256 electrodes covering your upper torso, and lay down. The 3-D image created is a road map of your heart with all the focal and rotor areas (A-Fib-producing spots) identified. During your ablation your EP simply ablates the “guilty” areas. Read more of my article…

Topera-FIRMap catheter - three sizes

The FIRM System

The FIRM system uses a different approach to mapping the heart and the A-Fib producing spots. It uses a basket catheter inside the heart to map large areas in a single pass and reveal the location of foci and rotors. Read more of my article…

Why are these two technologies important? ECGI allows your imaging & mapping to be performed the day prior to your ablation, rather than during your ablation. This shortens the length of your ablation procedure.  In addition it reduces your radiation exposure and produces remarkably accurate 3D images of your heart and identifies where A-Fib signals are coming from. The FIRM system, though performed during an ablation rather than before it, may be a significant improvement over the Lasso catheter mapping system now in current use. Both systems may mark a new level of imaging/mapping for A-Fib.

Flexible Biomechanical Balloon Catheter - photo credit: Dae-Hyeong Kim-University of Illinois

Stretchable Electronics Meets the Balloon Catheter

The merging of living systems with electronic systems is called “bioelectronics”. Key is a flexible, pliable circuit made from organic materials—the carbon-based building blocks of life. Bioelectronics have entered the EP lab with a prototype of a ‘bioelectronic catheter’, the marriage of a pliable integrated circuit with a catheter balloon.

In a mapping application, the deflated bioelectronic balloon catheter is slipped into the heart, then pumped up. The inflated integrated circuit conforms to the heart’s grooves and makes contact with hard-to-reach tissue. It can map a hundred electrical signals simultaneously, across a wider area and in far greater detail than had been previously possible. And it’s being developed to function in reverse. For ablation applications, instead of detecting current, it can apply precise electrical burns. This is a potentially breakthrough technology that may well change the way catheter mapping and ablation are performed. (Thanks to David Holzman for calling our attention to this ground-breaking research article.)

This is a remarkable time in the history of A-Fib treatment. Three very different technologies are poised to radically improve the way A-Fib is detected, mapped and ablated. We’ll look back at 2013 as a watershed year for A-Fib patients.

Three New Anticoagulants

In 2013 we saw three new anticoagulants, a welcome development for A-Fib patients. Note: the new anticoagulants are very expensive compared to the proven anticoagulant warfarin.

pradaxa_logo 150 pix 96 res Eliquis apixiban logo 150 pix 96 res Xarelto logo 150 pix 96 res

How do they compare to warfarin?

Warfarin seems to have a slightly higher chance of producing intracranial bleeding.
In general stay away from Pradaxa. There are horrible ER reports of patients bleeding to death from even minor cuts, because there is no antidote or reversal agent. Read more about my Pradaxa warning

Eliquis, in general, tested better than Xarelto in the clinical trials, but it’s so new we don’t have a lot of real-world data on it yet. And, as with Pradaxa, neither have antidotes or reversal agents.
In addition, there was what some consider a major problem with the clinical trials comparing the new anticoagulants to warfarin. ‘Compliance’ rates by warfarin users were poor (many either weren’t taking their warfarin or weren’t in the proper INR range). Did this skew the results?

And finally, unlike warfarin where effectiveness can be measured with INR levels, we don’t have any way to measure how effectively the new blood thinners actually anticoagulate blood. Read more of my article Warfarin vs. Pradaxa and the Other New Anticoagulants“.

Keep in mind: ‘New’ doesn’t necessarily mean ‘better’ or ‘more effective’ for You.

A-Fib with high blood pressure?

High Blood Pressure with Your A-Fib? Is Renal Denervation a solution?

As many as 30% of people with A-Fib also have high blood pressure which can’t be lowered by meds, exercise, diet, etc. There was hope that Renal Denervation would help.

With Renal Denervation, an ablation catheter is threaded into the left and right arteries leading to the kidneys, then RF energy is applied to the nerves in the vascular walls of the arteries, hopefully reducing ‘Sympathetic Tone’, lowering high blood pressure and reducing A-Fib. For many people Renal Denervation seemed the only realistic hope of lowering their high blood pressure. However, the Medtronic Simplicity-3 trial indicated that renal denervation doesn’t work. Read more of this article…  For 2014 news on this topic, read more…

A Study of Obesity and A-Fib: A-Fib Potentially Reversible

Apple and tape measure - weight loss 200 pix by 96 resObesity is a well known cause or trigger of A-Fib, probably because it puts extra pressure and stress on the Pulmonary Vein openings where most A-Fib starts.

In 2013 A research study report focused on obese patients with A-Fib. Those who lost a significant amount of weight also had 2.5 times less A-Fib episodes and reduced their left atrial area and intra-ventricular septal thickness.

Good news! Losing weight can potentially reverse some of the remodeling effects of A-Fib. Related article: Obesity in Young Women Doubles Chances of Developing A-Fib.

Data collected in a typical sleep study

Obstructive Sleep Apnea and A-Fib

Obstructive Sleep Apnea (OSA) is another well recognized cause or trigger of A-Fib. Anyone with A-Fib should be tested for sleep apnea.

Earlier studies have shown approximately two-thirds (62%) of patients with paroxysmal or persistent A-Fib suffer from sleep apnea. In 2013, research reports showed that the worse one’s sleep apnea is, the worse A-Fib can become. In addition, sleep apnea often predicts A-Fib recurrence after catheter ablation.

Before an ablation, Dr. Sidney Peykar of the Cardiac Arrhythmia Institute in Florida, requires all his A-Fib patients be tested for sleep apnea. If they have sleep apnea, they must use CPAP therapy after their ablation procedure.

A-Fib.com: Our New Website’s First Year

A-Fib_com logo The original A-Fib.com web site was created using the phased out software MS FrontPage. Thanks to a  “no strings attached” grant from Medtronic, A-Fib.com was reinvented with a more up-to-date but familiar look, and features more functionality (built on an infra-structure using Joomla and WordPress). We can now grow the site and add features and functions as needed.

It involved a tremendous amount of work. A special thanks to Sharion Cox for building the new site and for technical support. My wife, Patti Ryan, designed the look and all graphics. (I can’t thank Patti enough; I’m so lucky!)

A-Fib.com Project:
Update the Directory of Doctors & Facilities

Steve and A-Fib.com bulk mailing to update the A-Fib.com Directory of Doctors and Facilities

Back when I started A-Fib.com in 2002, there were less than a dozen sites performing ablations for A-Fib. Today our Directory of Doctors and Facilities lists well over 1,000 centers in the US, plus many sites worldwide.

Increasingly, doctors were writing me asking why they weren’t included, or why their info was incorrect since they had moved, etc. To update our records and our service to A-Fib patients, starting in July 2013, we prepared and mailed letters to over 1,000 doctors/facilities. We asked each to update/verify their listing (and include a contact person for our use).

Note to Doctors! If you haven’t updated your listing in our A-Fib.com Directory of Doctors and Facilities, just use our Contact Us form to email me and I’ll send you the form to fill in and return.

The response to our bulk mailing was great. The data input started in October and continued for several months (as time allowed). Recently, we cut over to the ‘new’ Directory menu and pages.

 


2014 PREVIEW A-Fib.com

What’s Ahead for A-Fib.com in 2014

2014 Boston AFib Symposium Reports: Check out my new reports from the 2014 Boston A-Fib Symposium (BAFS) held January 9-11, 2014 in Orlando FL.

The first two reports are posted. Look for more reports soon. I usually end up with 12-15 reports in total.

Steve and bulk mailing to update the A-Fib.com Directory of Doctors and Facilities

Our a-Fib.com Directory of Doctors & Facilities: Work on updating our listings is still underway. We need to contact those who did not respond to our request for verification or updating of their listing. (Shall we write again or maybe make phone calls?)Beat Your A-Fib by Steve S Ryan, PhD

Amazon Best Sellers list:  Our book sales continue to grow. Did you know that our book ‘Beat Your A-Fib’ has been on Amazon’s Best Sellers list continually in two categories (Disorders & Diseases Reference and Heart Disease) since its debut in March 2012? Visit Amazon.com and read over 40 customer reviews.

Help A-Fib.com Become Self-sustaining: We plan to step up our efforts to make A-Fib.com a self-sustaining site. (Since 2002, Steve and Patti Ryan have personally funded A-Fib.com with an occassional reader’s donation.)


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Bookmark this link!
Spreadshirt shop= Beat your a-fib - 4 piece 240 x 150 at 96

Visit our shop at Spreadshirt.com.

In our efforts toward sustainabiliy, several years ago we added a PayPal ‘Donate’ button (you don’t need a PayPal account to donate) and invited donations toward our onlline maintenance costs.

Then, a year or so ago, we added a portal link to Amazon.com. When you use our Amazon.com link, A-Fib.com receives a small commission on each sale (at no extra cost to you).

Our newest effort is our ‘A-Fib can be Cured! shop with T-shirts and more at Spreadshirt.com. With each shirt purchase $2 goes to support A-Fib.com. (We will roll out new designs every quarter or so).

Posted February 2014

Help A-Fib.com become self-sustaining! Help keep A-Fib.com independent and ad-free.
Will 2014 be the year you help support A-Fib.com?

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Last updated: Wednesday, February 11, 2015

Subject Index to A-Fib.com Articles for Additional Reading

Book of heart 2 Red in box 150 x 96Subject Index to A-Fib.com Articles

This index is a growing list of articles found throughout the A-Fib.com site that augment or supplement the major topics (each subject title is a link). If you have a keyword or topic, you can also use the ‘Search’ feature in the upper right corner of every page. New posts are flagged in Red.

Select a subject to browse articles:

♥  Dealing with Atrial Fibrillation

♥  Diagnosis & Testing

♥  Minerals Deficiencies & Supplements

♥  Drug Therapies & Medications

♥  Catheter Ablation, CyroBalloon and Pulmonary Veins Isolation

♥  Surgeries: Maze/Mini-Maze, Convergent, LAA Closure

  AF Symposium Articles by Year: Steve’s Summary Reports

♥  Research and Innovations


Didn’t find what you’re looking for?
Try the ‘Search our Site’ feature (top right of every page)


Return to A-Fib.com home page
Last updated: Monday, March 2, 2015

Article Index: Diagnostic Testing

Book of heart 2 Red in box 150 x 96Article Index

Diagnosis & Testing

At-Home Testing for Sleep Apnea with WatchPAT Device (Feb 2015) NEW

A Primer: Ambulatory Heart Rhythm Monitors

Guide to DIY Heart Rate Monitors & Handheld ECG Monitors (Part I) REVISED APRIL 2015

Guide to DIY Heart Rate Monitors: How They Work For A-Fib Patients (Part II) NEW

Understanding the EKG Signal

The CHADS2 Stroke-Risk Grading System UPDATED


Didn’t find what you’re looking for? Try the ‘Search our Site’ feature (top right of every page)


Return to Subject Index to A-Fib.com Articles Last updated: Tuesday, April 14, 2015

FAQs Coping with A-Fib: Monitors for Diagnosing Atrial Fibrillation

FAQs Coping with A-Fib: Monitors

12. “Is there any way to tell how often I get A-Fib or how long the episodes last? What kind of A-Fib monitors are available? I have silent A-Fib (A-Fib without any obvious symptoms). It was discovered by accident when I was getting an EKG during a physical.”

Holter Monitor

Holter Monitor

Your doctor may use a Holter or an Event Monitor. A Holter Monitor records your EKG continuously, usually for 24 hours; an Event Monitor can be used for up to 30 days or longer. For a more in depth discussion about Holter and Event monitors, see my report A Primer: Ambulatory Heart Rhythm Monitors.

Consumer Heart Rate Monitors by Polar

Consumer Heart Rate Monitors by Polar

To monitor for A-Fib yourself, try a consumer, or DIY, sports heart rate monitor available from sporting goods stores. Used by runners and other athletes, they rely on the use of a chest strap to pick up the electrical signals from the heart and transmit to a special wrist watch.

On most you can program a high heart rate zone which you might enter only if you were in A-Fib. That way you could record when and how long you stayed in A-Fib and what your max heart rate was. Some have internal storage recording that can be download to your PC to view data in a graphic form.

We like the “Polar” brand. Check out the array of Polar brand heart rate monitors on Amazon.com. Other companies include Timex, Garmin, Acumen, Nike, and Cardiosport.

For an in-depth review of DIY/sports monitors, see my report: Consumer (DIY) Heart Rate Monitors and my Shopping Guide to DiY Monitors.

Back to FAQs: Coping with Your A-Fib

FAQs Coping with A-Fib: DIY Heart Rate Monitors

 FAQs Coping with A-Fib: DIY Monitors

See MyPulse by Smart Monitors- long range at Amazon.com

MyPulse (long distance) by Smart Monitors at Amazon.com

17. “I care for my mom who has A-Fib. She is 94 and sees a doctor on a regular basis. She gets A-Fib attacks maybe once every two weeks and usually in the morning. But I work full time. Is there a heart rate monitor my mom can wear that would alert me when her heart rate is over a certain number? That way I can be alerted even when I’m at work.”

Yes, MyPulse by Smart Monitors, Inc. has a solution for you. This is a practical alternative to the expense of a medical monitoring service if you are just interested in simple heart rate data. Most consumer heart rate monitors rely on a chest strap which transmits heart rate data to a wristwatch. The MyPulse Long Range Monitor has a small Repeater device carried by the person wearing the chest strap. The Repeater transmits the data to a Receiver which is connected to a PC/notebook via a USB port. The MyPulse application runs on a PC and provides a graphic display of real time heart rate data.

The software can be configured to provide alerts via email or text message to multiple recipients if a preset heartbeat limit is exceeded.

Here are the cool parts: the software can be configured to provide alerts via email or text message to multiple recipients if a preset heartbeat limit is exceeded (such as might occur if the wearer goes into A-Fib). For the more tech savvy, a PC mirror app on your smart phone lets you view real time heart rate data at anytime, anywhere. Check out the MyPulse website or see the array of MyPulse the Smart Monitors on Amazon.com. For a more in depth discussion see Treatments/Diagnostics: A Primer: Ambulatory Heart Rhythm Monitors.

(Thanks Julie Skarbeck for this important question and to Ed Webb for doing the research and writing about the Smart Monitor.)

Back to FAQs: Coping with Your A-Fib

FAQs Coping with A-Fib: Diagnosis

 FAQs Coping with A-Fib: Diagnosis

FAQs A-Fib afib11. “How can I tell when I’m in A-Fib or just having something like indigestion?”

Without medical help you may not be able to tell the difference. (It’s been reported that indigestion is sometimes a side effect of an A-Fib attack.) Only a doctor can determine if you have A-Fib.

To verify if you have A-Fib, a doctor will use an ECG test or have you wear a monitoring system such as a Holter or an event monitor. To read more about these monitors, see my report: A Primer: Ambulatory Heart Rhythm Monitors.

If you want to monitor yourself (which may not necessarily be a good idea), you can start by taking your own pulse.

ARVE Error: Mode: lazyload is invalid or not supported. Note that you will need the Pro Addon activated for modes other than normal.

VIDEO: “Know Your Pulse” Awareness Campaign A short video on why and how to take your pulse. From the Arrhythmia Alliance (A-A) and The Heart Rhythm Charity in the UK. (Our British friend Trudie Lobban is Founder and Trustee.) (1:56 min)

Or you can use an over-the-counter DIY heart monitoring device such as those used by runners and other athletes

Consumer Heart Rate Monitors by Polar

Consumer Heart Rate Monitors by Polar

It’s worn around your chest and transmits a signal to a wristwatch that beeps when your pulse goes too high. You can check the digital display on the watch to see how fast your pulse is. For an in-depth review of DIY/sports monitors, see my report: Consumer (DIY) Heart Rate Monitors and my Shopping Guide to DiY Monitors.

Warning: any over-the-counter device is no substitute for monitoring and treatment by a doctor. You should not use over-the-counter devices to diagnose yourself.

Back to FAQs: Coping with Your A-Fib

ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping-2014 Boston AF Symposium

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

2014 Boston AF Symposium

ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping

Report by Dr. Steve S. Ryan, PhD

In a further discussion of the ECGI mapping and ablation system, Dr. Phillip Cuculich of the Washington University School of Medicine in St. Louis, MO gave a presentation entitled “Advances in and Limitations of Noninvasive Mapping of AF.” (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging ECG (ECG).

Background: ECGI stands for Non-Invasive Electrocardiographic Imaging used at Yoram Rudy’s lab at Washington University in St. Louis to understand the mechanisms of heart rhythm disease. A similar system called Electrocardiographic Mapping (ECM/ecVUE) uses similar technology, but has been developed and tested for clinical use in Europe (http://www.cardioinsight.com) and has different goals. Each group works independently and has different ways to seek solutions.
The software used by the ECGI system to produce data and images from the multi-channel ECG mapping and CT scan is called CADIS.

POTENTIAL BENEFITS OF ECGI

Dr. Cuculich began by describing the potential benefits of ECGI:

•  Save time: Locate the arrhythmia in a single beat
•  Better Preparation: Understand and plan for the arrhythmia before an ablation
•  Avoid Frustration: Map and ablate unstable, transient or complex arrhythmias
•  Research Platform for Discovery: Identify and describe the mechanisms of arrhythmias

A-FIB PATTERNS OR SIGNALS AS REVEALED BY ECGI

After imaging patients with ECGI, A-Fib patterns are a combination of mechanisms:

•  In simple A-Fib, Dr. Cuculich showed movies of left pulmonary vein focal sites with 1 to 2 wavelets and a left-to-right activation pattern

•  In complex (Long-standing Persistent) A-Fib, he showed movies of four or more simultaneous wavelets, a high degree of wavelet curvature, and frequent wave breaks (no focal sites). The patterns tend to repeat and follow a preferred path.

FIRM AND ECGI COMPARISON

FIRM

ECGI

Inside the heart Outside the heart (body surface mapping)
Up to 64 contact electrodes to produce up to 64 electrograms 1000 reconstructed electrodes
QRST subtracted No signal subtraction
70% rotor, 30% focal Multiple wave fronts (1-4), 15% rotor
Stable beat-to-beat Transient focal activity, transient rotational circuits

(In the ECGI imaging/mapping system the number of points on the heart is changeable. But they have found 1000 to be a good number for reliable, detailed analysis.)

Dr. Cuculich compared ECGI data to recent invasive epicardial (inside-the-heart) mapping and body surface mapping (called “Phase Lock”). The data showed significant agreement between the imaging systems. Also, ECGI compares favorably to surgical maze mapping data.1

But compared to FIRM, the most common patterns of A-Fib Dr. Cuculich found were multiple wavelets, with pulmonary vein and non-pulmonary vein focal sites. Rotor activity was seen rarely.2

NO STANDARD DEFINITION OF “ROTOR”

There is no standard definition of a rotor. In Dr. Cuculich’s studies he used 2 rotations at the same spot as a “rotor.” This is perhaps why he found less rotors than in the FIRM system and in the CardioInsight system as described by Dr. Jais where they found 80% rotors. See: BAFS 2014 Jais, ECGi & Circular Catheter 

Another major difference in ECGI and FIRM is that ECGI uses wavelet analysis (activation of the wavefront), while FIRM and CardioInsight uses phase mapping to describe the behavior of the arrhythmia. The main point of Dr. Cuculich’s presentation is that one must be very careful when applying phase techniques, as it can introduce rotor behavior into the imaging map. Dr. Cuculich’s group is studying whether this rotor behavior may be a true cause for the maintenance of A-Fib or just an artifact.

ECGI—TOO MANY ELECTRODES?

In a conversation with the author, Dr. Cuculich brought up comments that perhaps ECGI/ECM uses too many electrodes to see stable rotors, that perhaps panoramic imaging with fewer electrodes could improve the identification of rotors. (ECGI has a much larger number of electrode points in the heart [usually 1000] compared to FIRM [64 max].) To test this hypothesis, he analyzed A-Fib using 64 spaced electrodes in each atrium vs. standard ECGI. It turned out that fewer electrodes did not help to visualize rotors.

PHASE MAPPING, WAVEFRONTS, WAVELET TRANSFORMATION, ACTIVATION PATTERNS

Dr. Cuculich introduced new concepts in the use of ECGI (at least to this author)—phase mapping and the importance of wavefronts or wavelet transformation in A-Fib signals. “ECGI uses wavelet transform looking at pure activation time.” He asked, “how does…phase mapping affect the result?” He related phase mapping to the CONFIRM concept of “phase lock” where a simple 12-lead ECG analysis can classify A-Fib mechanistically.3

Doctors (and we patients) are still struggling to understand what phase mapping and wavelet transformation actually mean. Dr. Cuculich’s studies of phase mapping techniques (Hilbert transform) in A-Fib show that phase mapping highlights and accentuates the curvature of a wavefront and thus indicates a rotor is present. According to Dr. Cuculich, phase mapping is highly dependent on the chosen cycle length. He concluded that “while published ECGI data used wavelet transform to identify activation patterns, phase mapping techniques (when performed carefully and correctly) may offer additive information.”

EDITOR’S COMMENTS:

We’re grateful to Dr. Cuculich for his comparison of ECGI and FIRM which helps us understand both imaging system better. But it’s definitely disturbing that both systems vary so greatly. Why does the FIRM system find 70% rotors and ECGI only 15%? Why are FIRM’s A-Fib signals stable and ECGI’s transient? Why does the FIRM system not focus on wavefronts and wavelet transformation?
One way to resolve these discrepancies would be to use a standard Lasso mapping catheter to meticulously map every potential A-Fib-producing spot in an animal or human with Long-standing Persistent A-Fib (where one would expect to find multiple A-Fib producing spots in the heart). Then immediately use both the FIRM and ECGI system to map the same heart and compare the results.
Perhaps the single biggest new discovery in human A-Fib mapping is rotors. But there’s considerable debate about their definition and behavior. Dr. Cuculich found that rotors are relatively rare (15%), whereas the FIRM and CardioInsight studies indicate that 70-80% of A-Fib drivers are rotors.
Dr, Cuculich introduced new concepts, insights and vocabulary to our understanding of A-Fib, (some of which I’m still having trouble wrapping my head around). Are wavefronts and wavelet transformation important in themselves or are they part of the development of rotors? Phase mapping and wavelet transformation applied to A-Fib is a major innovation that may lead to a better understanding of how A-Fib signals activate in the heart. Besides making mapping and ablating A-Fib easier and more effective, ECGI with its detailed, high resolution capabilities may give us new insights into A-Fib.

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Last updated: Wednesday, September 2, 2015 

References    (↵ returns to text)
  1. Lee, G. et al. Epicardial wave mapping in human long-lasting persistent atrial fibrillation: transient rotational circuits, complex wavefronts, and disorganized activity. European Heart Journal (2104) 35, 86-97. Last accessed May 13, 2013, URL:http://www.ncbi.nlm.nih.gov/pubmed/23935092 doi:10.1093/eurheartj/eht267
  2. Cuculich, PS et al. Noninvasive characterization of epicardial activation in humans with diverse atrial fibrillation patterns. Circulation. 2010 Oct 5; 122(14): 1365-72. Last accessed May 13, 2013, URL: http://tinyurl.com/okp4229
  3. Non-invasive identification of stable rotors and focal sources for human atrial fibrillation: mechanistic classification of atrial fibrillation from the electrocardiogram, Europace. February 28, 2013. Last accessed May 13, 2013, URL: http://tinyurl.com/njt9zd7; doi:10.1093/europace/eut038

How ECGI Works by Dr. Haissaguerre-2014 Boston AF Symposium

Dr Michele Haissaguerre

Michel Haissaguerre MD

2014 Boston AF Symposium

How ECGI (Non-Invasive Electrocardiographic Imaging) Works

Report by Dr. Steve S. Ryan, PhD

Dr. Michel Haissaguerre of the LIRYC Institute in Bordeaux, France gave a presentation entitled “Mechanistic Insights From Noninvasive Mapping of AF—Implications for Catheter Ablation.”

Dr, Haissaguerre began by discussing the concept of voltage vs. noise in reading an ECG. High accuracy can be obtained with a EGM (electrogram signal) of >0.15mV. Body Filtering (ECGI) can miss small local A-Fib signals, but does not affect global patterns.

He found that when mapping Focal A-Fib signals from both inside and outside the heart, they may differ in location by 3.1mm. (This is a relatively small difference and isn’t enough to affect the overall accuracy of the mapping and ablation.)

How ECGI (Body Mapping) Works

He described how the ECGI system works. A patient lies down on his/her back and a technician places a vest-like device with 256 electrodes over his/her chest and stomach. These electrodes combine with rapid CT (Computed Tomography) scans to produce a very detailed 3D color map of the heart. (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging [ECG])

The system automatically detects rotors and foci and computes them into a “Cumulative Map” or movie. These driver regions are ranked, based on statistical prevalence. Dr. Haissaguerre showed slides of these drivers originating from PVs in Paroxysmal A-Fib.

In persistent A-Fib he found multiple interplaying driver regions (median 4, 1 to 7) found in the Left Atrium, PVs and Right Atrium (“driver regions” include both focal sources and rotors). The rotors were temporally and spatially unstable. They were not sustained. Most had 2-3 rotations with a mean of 448ms. They required a statistical analysis of their core trajectory/density. Patients in Persistent Long-Lasting A-Fib for more than six months had the most driver regions and the least success in A-Fib termination after six months.

…ECGI ablation significantly reduced the amount of burns needed to terminate A-Fib.

Compared to the traditional Bordeaux step-wise ablation for persistent A-Fib, ECGI ablation significantly reduced the amount of burns needed to terminate A-Fib.

Dr. Haissaguerre uses a Multielectrode circular catheter not yet approved for use in the US. This catheter can more easily capture and isolate regional targets like rotors that do move a little.

Dr. Haissaguerre’s Conclusions

  • Regional clusters of A-Fib drivers can be mapped non-invasively
  • ECGI mapping before a procedure identifies critical regions to ablate. This reduces targeted atrial areas and RF delivery. The optimal timing is in the early months of persistent A-Fib.
  • There is a need for appropriate ablation tools (such as circular or multielectrode catheters) as rotor targets are not so limited (they tend to move slightly).
Editor’s Comments:
Back in 2013 I predicted that “the ECGI system, barring unforeseen circumstances, will rapidly supersede all other mapping systems and will become the standard of care in the treatment of A-Fib patients.”
Not only does the ECGI system produce a complete, precise, 3D, color video of each spot in a patient’s heart producing A-Fib signals, but also an ECGI can be done by a technician before the procedure rather than by a doctor during an ablation. And the ECGI map is a better, more accurate, more complete map than an EP can produce by using a conventional mapping catheter inside the heart.
From a patient’s perspective, ECGI reduces both the time it takes to do an ablation and the number of burns a patient receives.
The only caveat that Dr. Haissaguerre found (which relate to all mapping strategies, not just to ECGI) is that rotors move slightly and are somewhat unstable. A computer has to be used to statistically analyze their core trajectory. But circular catheters can be used to contain and isolate them.

Addendum: April 2015

Jeffrey Patten asked, “I’ve heard that the new mapping and ablation vest system ECGI (CardioInsight), though very detailed with 256 electrodes, doesn’t directly map the septum area. Is that correct?”

It’s correct to say the ECGI does not directly map the septum area. But, that doesn’t mean the septal activity can’t be mapped with the ECGI.
I posed your question to the world-reknown cardiologist, Dr. Pierre Jais of the Bordeaux group. He explained that “the septal activity projects at the anterior and posterior attachments of the septum on both atria.” He added that mapping the septum with the ECGI system “…requires some experience, but is at the end easy.”
So don’t be reluctant to seek out the new mapping and ablation vest system ECGI (by CardioInsight). Just be sure you have a top-notch, experienced operator.

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Last updated: Wednesday, September 2, 2015 

Advances in Heart Imaging And Mapping Systems

by Steve S. Ryan, PhD

Perhaps the most important technical innovations in 2013 for A-Fib patients were the introduction of two new heart imaging and mapping systems. A third system, the Bioelectronic Catheter, represents a whole new technology with tremendous potential for A-Fib patients.
Patients wearing 'vest' lies down for the ECGI.

Patients wearing ‘vest’ lies down for the ECGI.

The ECGI System

The ECGI system, combined with a CT scan, produces a complete 3-D image of your heart along with identifying all the A-Fib-producing spots. Think of it as an ECG with 256 special high resolution electrodes rather than 12. It greatly reduces your ablation time and your radiation exposure. A day before your ablation, you simply don a special vest with 256 electrodes covering your upper torso, and lay down.

The 3-D image created is a road map of your heart with all the focal and rotor areas (A-Fib-producing spots) identified. During your ablation your EP simply ablates the “guilty” areas. Read my article: BAFS 2013: Non-Evasive Electrocardiographic Imaging (ECGI)

Topera-FIRMap catheter - three sizes

Topera-FIRMap catheter – three sizes

The FIRM System

The FIRM system uses a different approach to mapping the heart and the A-Fib producing spots. It uses a basket catheter inside the heart to map large areas in a single pass and reveal the location of foci and rotors. Read more of my article on the FIRM System… Why are these two technologies important? ECGI allows your imaging & mapping to be performed the day prior to your ablation, rather than during your ablation. This shortens the length of your ablation procedure.

In addition it reduces your radiation exposure and produces remarkable accurate 3D images of your heart and where A-Fib signals are coming from. The FIRM system, though performed during an ablation rather than before it, may be a significant improvement over the Lasso catheter mapping system now in current use. Both systems may mark a new level of imaging/mapping for A-Fib.

Flexible Biomechanical Balloon Catheter - photo credit: Dae-Hyeong Kim-University of Illinois

Flexible Biomechanical Balloon Catheter – photo credit: Dae-Hyeong Kim-University of Illinois

Stretchable Electronics Meets the Balloon Catheter

The merging of living systems with electronic systems is called “bioelectronics”. Key is a flexible, pliable circuit made from organic materials—the carbon-based building blocks of life. Bioelectronics have entered the EP lab with a prototype of a ‘bioelectronic catheter’, the marriage of a pliable integrated circuit with a catheter balloon.

In a mapping application, the deflated bioelectronic balloon catheter is slipped into the heart, then pumped up. The inflated integrated circuit conforms to the heart’s grooves and makes contact with hard-to-reach tissue. It can map a hundred electrical signals simultaneously, across a wider area and in far greater detail than had been previously possible. And it’s being developed to function in reverse.

For abaltion applications, instead of detecting current it can apply precise electrical burns. This is a potentially breakthrough technology that may change the way catheter mapping and ablation are performed. (Thanks to David Holzman for calling our attention to this ground-breaking research article.)

What a remarkable time in the history of A-Fib treatment! Three very different technologies are poised to radically improve the way A-Fib is detected, mapped and ablated. We’ll look back at 2013 as a watershed year for A-Fib patients.
References for this article

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Last updated: Sunday, February 15, 2015

Guide to DIY Heart Rate Monitors & Handheld ECG Monitors (Part I)

Consumer Heart Rate Monitors (HRMs) and Handheld ECG monitors

by Steve S. Ryan, PhD, Updated April 2015

A-Fib patients sometimes want to monitor their heart rate and pulse when exercising or when performing physically demanding activities (i.e., mowing the lawn, climbing stairs, loading and unloading equipment, etc.). A consumer ‘DIY” monitor or Handheld ECG monitor may meet this need.

We’ve sorted through the plethora of products and brands and recommend several products in a range of prices and features.

 Types of Consumer HRS

Consumer, DIY or ‘Sport’ Heart Rate Monitors (HRM) are designed for runners and other recreational athletes to collect helpful data for lifestyle and training (pace, distance, heart rate, pulse, etc.).

Heartbeat sensors are either attached to a chest (or arm) band or built-in to wearable technology and paired with a wireless link to a wrist watch or app-enabled smartphone. HRMS are available from sporting goods stores and online from Amazon.com and other sites.

The Gold Standard brand for HRMs is Polar. (The first EKG accurate wireless heart rate monitor was invented by Polar back in 1977 as a training tool for the Finnish National Cross Country Ski Team.) You can view the extensive range of Polar products at PolarUSA.com. Other companies offering consumer ‘Sport Heart Rate Monitors’ include Timex, Garmin, Acumen, Nike, and Cardiosport plus a host of others if you shop around.

To learn how HRMs work, recording capabilities and how they can help A-Fib patients monitor their heart rate, see our article DIY Heart Rate Monitors: How They Work For A-Fib Patients (Part II).

To help you sort through their extensive offerings, I narrowed down the choices to a few basic and advanced wristwatch models, Bluetooth models, and the newer wearable technology each in an array of price points.

Polar FT4

Polar FT4 with chest band sensor

Wrist Watch Monitors

Consists of two components. These HRMs use sensors attached to a heart rate strap that wraps around the chest, and sends a wireless signal to the wrist unit. Some models connect with compatible gym equipment using GymLink. (More features = higher prices.) A few to consider:

♥  Polar FT4 Heart Rate Monitor Watch (about $45)
♥  Polar RS300X Heart Rate Monitor (about $85)
♥  Polar FT60 Fitness Heart Rate Monitor Watch ($100-$110)
♥  Polar M400 GPS Sports Watch & Activity Tracker (about $150-$350)

GObeat bluetooth

GObeat Bluetooth HRM for use with Smartphones

Bluetooth App-Enabled Monitors for Smartphones

Smartphones are now ubiquitous. For many, their smartphone is an essential part of their standard gear. So, it’s no wonder that a smartphone can replace the wrist watch monitor. Today, you can use Bluetooth technology to send the signal from your heart rate chest strap to an app-enabled smartphone. Here are a couple to consider:

♥  Polar H7 Bluetooth Smart Heart Rate Sensor (about $65)
♥  60beat BLUE Heart Rate Monitor for iPhone and most newer Androids (about $35)
♥  Jarv Premium Bluetooth® 4.0 Smart Heart Rate Monitor for Android Devices (about $28)

Bandless Sensors

A replacement for the chest strap for those who find a chest strap uncomfortable or chafing, “wearable technology” offers new options.

Wearable technology

Wearable technology

With these workout clothes, sensors are built in—to a women’s jogging bra or men’s t-shirt (there are also HRM caps, headbands and visors). For example:

♥  Weartech Men’s Gow Smart Sports T-Shirt (Intergrated Cardiac Sensors) ($59-$79)
♥  Weartech Women’s Gow Smart Sports Bra (Intergrated Cardiac Sensors) ($39-79)
♥  Polar Cardio Sports Bra  (about $49)

Note: these items replace the chest band only. Unless sold as a set, you still need a Heart Rate monitor to snap on to the front of the garment such as the
♥   GOW Bluetooth 4.0 Heart Rate Monitor (about $40)
and you will need something to receive the signal—a wrist watch monitor or app-enabled smartphone.

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 Types of Handheld ECG Monitors

See “Comparison of handheld, 1-lead/channel ECG / EKG recorders” by James W. Grier, for an extremely detailed report of 14 Handheld ECG Monitors

This category of consumer monitors has been growing of late with some models having only limited track records. Going beyond just monitoring your heart rate, these units capture data and display it as an ECG (EKG) in real time. (Some units in this category require a doctor’s prescription.)

With prices ranging from $129 to $500 you need to consider size (portability) and ease of use compared to price. Again, I’ve selected a few handheld ECG monitors from the plethora of choices.

AliveCor Heart Monitor by AliveCor

Left: AliveCor snap-on unit (3rd generation); Right: AliveECG app on smartphone screen

Excerpt from Patient Review: AliveCor Heart Monitor for SmartPhones by Frances Koepnick:

FDA-cleared for detection of atrial fibrillation (A-Fib), the AliveCor Heart Monitor when combined with its AliveECG App provides a 30-second, one lead electrocardiogram (ECG). In addition to an ECG, this monitor also determines heart rate in beats per minute (BPM).

This easy-to-use device attaches to iPhones (models 4 thru 6) by means of a snap-on phone case. It is also available for some compatible smartphones and mobile devices other than iPhones.

AliveCor ECG reading displayed on smartphone screen

AliveCor ECG reading displayed on smartphone screen

An ECG reading is obtained by holding the iPhone with both hands and placing at least 1 finger from each hand on the electrodes embedded into the back of the phone case. Your data is accessible through the AliveECG app. it’s also stored on AliveCor secure, encrypted servers, so you can view them anywhere and share them with your doctor.

For more specifics on the AliveCor AC-009-UA-A, continue reading our February 2015 report Patient Review: AliveCor Heart Monitor for SmartPhones by Frances Koepnick.

Note: Be sure to get the newest model—the 3rd generation. (Doctor prescription no longer required.) About $75.

The HeartCheck™ PEN handheld ECG device from CardioComm Solutions

HeartCheck - unlock view 400 pix wide at 96 res

HeartCheck Pen

The HeartCheck™ PEN handheld ECG device is the only device of its kind cleared by the FDA for consumer use. No prescripton required. (A second device, the HeartCheck™ ECG Handheld Monitor does require a prescription to order.)

The pocket-sized PEN allows you to take heart readings from anywhere, the moment symptoms appear. Then using the USB cable provided, connect the device to your PC and run ‘GEMS™ Home’ program to upload your heart rhythm files containing your ECGs and send it to a physician or ECG Coordinating Center (for a fee).

There’s a good review of the Heart Check pen by  over at LivingWithAtrialFibrillation.com (posted Sept. 2013). Robert goes into great detail about how to “unlock” your device so you can see the actual reading, the costs of reports (the first one is free), and the details about how all this works. There’s even a $20 off discount code if you order from the manufacturer’s website.

There are also user videos at: HeartCheck™ ECG PEN Tips and Common Errors

Keep in mind that the HeartCheck™ PEN reports aren’t meant to be used for diagnosis. Reviews on Amazon.com are mixed, but it may work for you. Read one or both of the reviews mentioned above. About $259.

Handheld ECG Monitor CMS-80A from FaceLake (or Contec Medical Systems)

Facelake Hand-Held Single Channel ECG, ECG 80A Link

Facelake Hand-Held ECG 80A

Note: Read about how Tom Burt used the CMS-80A in his Personal Experience story. He writes, “This came in very handy as a way to inform my EP when I did get out of rhythm. This was done by faxing him a strip of the printout.”

The Contec CMS-80A is a single channel, 12 lead monitor which can provide data via one of three ways: on the unit display, via the thermal printer internal to the unit or via a USB connection to a PC. The printout from the unit offers the easiest and most accurate means to view lead output. While you can view lead output on the display, you will find that it is not to the same level of detail as the printout.

Like most normal ECG monitors, 10 electrodes are attached to the body as follows: 6 suction cup leads to the chest and 4 alligator clip leads to the arms and legs. The unit does not rely on the normal press-on style contacts but rather takes a simpler approach with its reusable contacts. Personally, I [Ed Webb] wasn’t too impressed with the suction cup style contacts as they feel funny and leave a mark as if you had been attacked by an octopus. But they seemed to do the job. The alligator clips, while funky, were quick and easy to attach.

Facelake Hand-Held Single Channel ECG, ECG 80A Link

Thermal paper in Facelake Hand-Held Single Channel ECG, ECG 80A – link

The waveforms presented are not what you would expect from an ECG in your cardiologist’s office, but they can provide the simple basics to make a quick determination whether you are in A-Fib. In particular, by examining the output from Lead II, or perhaps Lead aVF, you can quickly observe the absence of a P wave—one sign that you may be in A-Fib. Additionally, examining R-R intervals and whether they are uniformly spaced can be another means to aid in that determination.

From a practical perspective, it could be that you choose to only attach the alligator leads to your arms and legs and forego using the chest leads. You will obviously not have the data from the chest leads (V1 to V6), but that information may not be needed for A-Fib purposes.

Thermal printout from the Handheld ECG Monitor CMS-80A ECG

Note: This unit does not require a prescription from your doctor. For more info and to see what the display looks like, visit the Contec product information page. The CMS-80A (ECG-80A) can be purchased directly from Facelake.com and other locations online ($299-$380).

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 Remote Smart Monitors

MyPulse Provides Email or Text Message Alerts

Are you worried about a relative in A-Fib whom you can’t be with all the time? There is a long range heart monitor your relative can use which will transmit to you if he/she goes into A-Fib or exceeds a normal heart rate.

MyPulse by Smart Monitors link

MyPulse (home model) by Smart Monitors

If you have a need to monitor a relative’s or friend’s heart rate or want to know if your relative or friend has gone into A-Fib, MyPulse by Smart Monitors, Inc. has a solution for you. (Prices range from  $149 – $495.) This is a practical alternative to the expense of a medical monitoring service if you are just interested in simple heart rate data. Obviously, if there are medical concerns relative to the heart arrhythmia, you should find an appropriate medical monitoring solution in concert with the patient’s cardiologist. But if you are looking for an alternative to a medical service, read on.

Most heart rate monitors rely on a chest strap which transmits heart rate data to a wristwatch, bike computer or even smart phone worn or carried by the individual. The MyPulse Long Range Monitor is no different, but instead of the watch to read the data, it has a small Repeater device which is carried by the individual (or located within 3’ of the person wearing the chest strap). The Repeater transmits the data to a Receiver which is connected to a PC/notebook via a USB port.

The combination of Repeater/Receiver gives the wearer a practical range of throughout the house (the kind of range you would expect to see on a Wi-Fi network for instance) and up to 1000’ if the Receiver has an unobstructed view of the Repeater. The MyPulse application runs on the PC and provides a graphic display of real time heart rate data.

Bluetooth mid range/global range monitor

This is the cool part: the software can be configured to provide alerts via email or text message to multiple recipients (such as a caregiver) if a preset limit is exceeded (such as might occur if the wearer goes into A-Fib). For you more tech savvy people, if you want to run a PC mirror app on your smart phone, you can view the real time heart rate data at anytime, anywhere, and not have to worry about waiting for an alert if a limit is exceeded.

All in all, this is a remote heart rate monitor solution that provides a low cost alternative to a medical monitoring service if you and your cardiologist determine you don’t need such a service. Check out the MyPulse by Smart Monitor, Inc. on their website and from Amazon.com (using our portal link).

March 2015 Update: Additional MyPulse solutions include Bluetooth models: Bluetooth mobilePlus edition monitor, $149 and Advanced home edition bluetooth mid range/global range monitor. $299.

 In-Depth Report Of ECG Monitors

Report: Comparison of Handheld, 1-lead/Channel ECG/EKG Recorders

I’m pleased to share a great online resource for anyone considering one of the newer hand-held ECG monitors. “Comparison of handheld, 1-lead/channel ECG / EKG recorders” by James W. Grier, Emeritus Professor of Biological Sciences, North Dakota State University. This report is extremely detailed and extensive (and was last updated January 26, 2015).

He tests and compares 14 units, includes multiple photos of each step of testing and multiple print outs of the results. It’s the most thorough report on the topic you will find anywhere.

Go to http://www.ndsu.edu/pubweb/~grier/Comparison-handheld-ECG-EKG.html

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Last updated: Wednesday, August 24, 2016

FIRM (Focal Impulse and Rotor Modulation) for Catheter Ablation of A-Fib by Dr. Narayan of UC San Diego

red-heart-negative 150 pix by 96 resby Steve S. Ryan, PhD

I have received several emails asking why I don’t write about Dr. Sanjiy M. Narayan’s studies. I must admit to not understanding some aspects of FIRM and was hoping further information would make things clearer.

Ablating focal beats and electrical rotors, or as Dr. Narayan describes them, “localized areas of electrical activity” is nothing new. (See 2011 Boston A-Fib Symposium, Using CFAEs in Ablating Persistent A-Fib, and 2009 Boston A-Fib Symposium, CFAEs vs. Dominant Frequency) Dr. Narayan’s FIRM procedure uses the largest 64-pole standard basket catheter to do the mapping and uses “monophasic action potentials” (MAPs) catheter mapping to physiologically identify the A-Fib generating spots in the heart.

Proprietary, Patented Algorithm

What is new is the proprietary, patented algorithm Dr. Narayan uses to display the optical images and movies of the activation. (A description of the signal processing Dr. Narayan uses is found in the article “Computational Mapping Identifies Localized Mechanisms for Ablation of Atrial Fibrillation.”) Topera Medical, which licensed this algorithmic-based mapping system, calls it RhythmView.

This author doesn’t understand how Dr. Narayan’s proprietary system differs from other non-proprietary systems using basket catheters to map focal beats and rotors, with the possible exception that he uses the largest basket catheter with a wide field of view to be able to map almost an entire atria at one time.

Targets Rotors and Focal Beats Before Any Other Ablation Sites

After ablating rotors and focal sources found by his FIRM mapping system, Dr. Narayan also ablates the pulmonary veins utilizing wide area circumferential ablation—similar to what is currently done in most A-Fib centers.

Dr. Narayan targets ablation at rotors and focal beats before any other ablation sites, including the pulmonary veins. “Ablation at only rotors and focal sources revealed by our mapping approach (without pulmonary vein isolation) terminated AF predominantly to sinus rhythm in seconds to minutes.”

According to Dr. Narayan, “patients undergoing this targeted ablation (FIRM) experienced a superior rate of AF elimination in the long-term compared to patients undergoing traditional ablation procedures focusing on trigger mechanisms near the pulmonary veins.” Yet, after ablating rotors and focal sources found by his FIRM mapping system, Dr. Narayan also ablates the pulmonary veins utilizing wide area circumferential ablation—similar to what is currently done in most A-Fib centers.

Others Start By Ablating the PVI First

Dr. Narayan’s approach differs from standard operating procedure in almost all centers which start with ablating or isolating the pulmonary vein openings first before moving to other areas.

To this author, Dr. Narayan’s approach doesn’t make intuitive sense. If the pulmonary veins are still firing when mapping is done of the rest of the atrium, wouldn’t these PV signals interfere with or confuse the mapping? In most paroxysmal A-Fib patients, isolating the pulmonary veins is often all that’s needed to eliminate A-Fib (these patients often don’t have any other sources of A-Fib signals outside of the pulmonary veins).

Dr. Narayan found that patients with persistent A-Fib had more sources than those with paroxysmal A-Fib, though these sources were few in number—only about 2 for both atria. This is in contrast to previous studies which have found a greater number of A-Fib producing spots, especially in persistent A-Fib patients.

Dr. Narayan found that almost one-quarter of A-Fib sources come from the right atrium.

Contrasts with Established Protocols

For persistent A-Fib patients Dr. Narayan makes a left atrial roof line ablation, and for those with typical atrial flutter he makes a cavotricuspid isthmus ablation. No other ablation is performed even for persistent A-Fib. This contrasts with established protocols for ablating persistent A-Fib. (See 2008 Boston A-Fib Symposium, Stepwise Approaches in Ablating Chronic A-Fib.)

Trial Results

PRECISE-PAF trial results of FIRM ablation for atrial fibrillation without pulmonary vein isolation (PVI). This was a multi-center trial performed at nine centers with 33 patients showed a 67% termination of A-Fib, with another 17% showing a greater than 10% slowing in their A-Fib.

This is a relatively few number of patients.

EDITOR’S COMMENTS: Perhaps the most important innovation of FIRM is the ability to map and ablate rotors and focal beats in “seconds to minutes.”
Right now doctors doing ablations on patients with persistent A-Fib spend a great deal of time and effort tracking down and ablating rotors and focal sources of A-Fib. If Dr. Narayan’s FIRM system makes this part of the ablation procedure easier, faster and more accurate, this would be a major medical breakthrough for A-Fib patients and doctors. 
(The author admits to not understanding how the FIRM system works compared to other systems using basket mapping catheters.)
But one can question the validity and accuracy of the FIRM system, since it typically finds only about 2 A-Fib sources in each atria.
It’s hard to compare Dr. Narayan’s results or to say his approach is superior to standard Pulmonary Vein Isolation. Most experienced A-Fib centers achieve around a 67% success rate as Dr. Narayan does. Though Dr. Narayan first ablates rotors and focal sources in the left atrium, he does later ablate the Pulmonary Veins like almost all other centers.
(It probably makes more sense to first ablate the PVs, then use the FIRM system to track down any A-Fib
A second important innovation of Dr. Narayan’s FIRM mapping system is the finding that one-quarter of A-Fib signals come from the right atrium. If future trials confirm this finding, doctors might have to change their ablation procedures and direct more attention to the right atrium.
References for this Article

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Return to Index of Articles: Research and Innovations

Last updated: Wednesday, September 2, 2015

The CHADS2 & CHA2DS-VASc Stroke-Risk Grading Systems

Stroke-Risk Grading Systems

Stroke-Risk Grading Systems

By Steve S. Ryan, PhD, Updated Nov 2014

In the US, doctors use what is called a CHADS2 stroke-risk grading system to help estimate the risk of stroke in patients with atrial fibrillation. A high CHADS2 score corresponds to a greater risk of stroke, while a low CHADS2 score corresponds to a lower risk of stroke. The CHADS2 score is simple and has been validated by many studies.

The patient’s stroke risk, i.e., their CHADS2 score, is estimated by adding together the points that correspond to the patient’s conditions.

“C” Congestive Heart Failure Score = 1

“H” Hypertension Score = 1

“A” Age over 75 Score = 1

“D” Diabetes Score = 1

“S2” Previous Stroke or TIA Score = 2

 A CHADS2 score of 2 or over would indicate someone should be on a blood thinner such as warfarin.

The CHADS2 score has been superseded in clinical use by the CHA2DS2-VASc score that is designed to give a better stratification of low-risk patients. It utilizes the same 5 major risk factors considered by CHADS2 but assigns a score of ‘2’ for patients older than 75 years, and adds 3 new risk factors: a history of vascular disease, age 65-74 years, and female sex which increase stroke risk. But according to the original study, “there was no statistically significant difference found between the CHA2DS2-VASc and CHADS2 risk stratification schema in predicting TE events”.

A-Fib Stroke Risk Calculators

CHAD2DS2VAC Medium 100 pix at 96 resUse this link to calculate your A-Fib stroke risk using the CHADS2 Calculator
Use this link to calculate your A-Fib stroke risk using the CHA2DS2-VASc Calculator

Classification of CHADS2 vs CHA2DS-VASc

In both scoring systems, a score of 0 is “low” risk of stroke, 1 is “moderate”, and any score above 1 is a “high” risk. The CHA2DS2-VASc system has three more variables and therefore will classify a greater number of patients into a high-risk group.

Editor’s comment: There is some controversy about the increased stroke risk for females. See articles on Dr. John M’s blog post and Aging Well magazine.
See also our article: Women in A-Fib Not at Greater Risk of Stroke, and The New CHA2DS2-VASc Guidelines and the Risks of Life-Long Anticoagulation Therapy.

References for this article

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Last updated: Thursday, September 3, 2015

Diagnostic Tests

Diagnostic Tests for Atrial Fibrillation - A-Fib.com, A-fib, afib, a fib

Diagnostic Tests for Atrial Fibrillation – A-Fib.com

Diagnostic Tests for Atrial Fibrillation

Doctors have several technologies and diagnostic tests to aid them in evaluating your A-Fib. Your doctor will likely make use of several from this list.

 Blood Test

Blood tests check the level of thyroid hormone, the balance of your body’s electrolytes (i.e., potassium, magnesium, calcium, sodium, etc.), look for signs of infection, measure blood oxygen levels and hormone levels, and other possible indicators of an underlying cause of Atrial Fibrillation.

Blood tests can also reveal whether a patient has anemia or problems with kidney function, which could complicate Atrial Fibrillation.

 Electrocardiography

An Electrocardiogram (ECG or EKG) is a simple, painless test that uses up to twelve sensors attached to your body to create a graphical representation of the electrical activity of your heart. The standard ECG records for only a few seconds. It can only detect an A-Fib episode if it happens during the test. For a longer period of time, a portable ECG monitor is used. 

VIDEO: Real-time EKG display of a heart. Test for Atrial Fibrillation, A-Fib, afib,  a fib

VIDEO 1: Real-time EKG display of heart in A-Fib

VIDEO 1: Watch a real-time EKG display of a heart in Atrial Fibrillation. (:30) (Hint: Turn down the music track.) Look for the rapid, but irregular tracing. Uploaded on Apr 19, 2009. By HeartStart Skills Frasco.

NOTE: For an in depth explanation of the ECG/EKG waveform signal and how to “read” an ECG tracing, see my report Understanding the EKG Signal.

 Holter and Event Monitors

Those with occasional A-Fib (Paroxysmal) may not experience an A-Fib episode during your ECG. So, doctors have other means of capturing your A-Fib data.

Holter Monitors

A Holter Monitor is a small, portable recorder that’s clipped to a belt, kept in a pocket, or hung around your neck and worn during your normal daily activities. The leads from the Holter Monitor attach to your body like the sensors of an ECG. The Holter Monitor records your heart’s electrical activity for a full 24–48 hour period in hopes of capturing data during an A-Fib attack.

Event Monitors

An Event Monitor is similar to a Holter Monitor, but records data only when activated by the patient. Pressing a button saves several minutes of data preceding and several minutes afterward. Some event monitors start automatically when they sense abnormal heart rhythms. You might wear an event monitor for one to two months.

VIDEO: Zio Patch cardiac monitor - "Band-Aid monitor" test for Atrial Fibrillation, A-Fib, afib, a fib

VIDEO 2: Zio Patch cardiac monitor

VIDEO 2: The “Band-aid” Cardiac Monitor. Instead of a bulky holter monitor, the Zio® Patch cardiac monitor looks similar to a 2-by-5-inch adhesive bandage and sticks to a patient’s chest. Steven Higgins, MD, talks about this single-use ambulatory cardiac monitor; the device can continuously monitor your heart rhythm for up to 14 days without the need for removal during exercise, sleeping or bathing. From a May 2012 TV news story. (1:52 min.)

Implantable Monitors

An Implantable Monitor is a type of event monitor without wires that’s inserted under the skin through a small incision. It’s used for patients with infrequent, unexplained fainting or passing-out when other tests have not found the cause. The implantable monitor is used for up to a year or more.

NOTE: For an in depth look at ECG monitors (including DIY/consumer heart rate monitors), see my report A Primer: Ambulatory Heart Rhythm Monitors.

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 Exercise Stress Test

During a stress test, you walk (or jog) on a treadmill while an ECG records your heart’s activity. This is often combined with an echocardiogram before and after the stress test to view and measure heart functions. 

 Tilt-Table Test

When the cause of dizziness, fainting or light-headedness isn’t detected by ECG or the Holter/event monitor, a tilt-table test may be performed. The table tilts the patient upright at a 70–80 degree angle for 30–45 minutes. As you are moved from a horizontal to an upright position, your blood pressure, heart rate and heart rhythm are monitored.

VIDEO: Patient introduction to the tilt table test. New York Cardiovascular Associates website, http://www.nycva.org/.

VIDEO 3: Patient introduction to the tilt table test.

VIDEO 3: Tilt table test: Patient introduction to the tilt table test. Description of the test as we see a technician take a patient through a tilt table test. (1:15) Video posted on the New York Cardiovascular Associates website.

 Electrophysiology Study

An electrophysiology study is a special catheterization test to examine the electrical activity inside your heart. It’s used to determine if and why the rhythm is abnormal. An electrophysiologist (EP) inserts several electrode catheters through the veins in your groin. Real-time images or moving X-rays (fluoroscopy) help guide the catheters into the heart. Once in place, the EP uses the catheters (and perhaps arrhythmia drugs) to artificially stimulate your arrhythmia. By recording data from strategic locations within the heart, most kinds of cardiac arrhythmias can be fully documented.

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 Imaging Technologies

Echocardiography (Cardiac Ultrasound)

An Echocardiograph uses ultrasound waves to create a moving picture of your heart. As special sound waves are bounced off the structures of your heart, a computer converts them into pictures. These images show the size and shape of your heart and how well your heart chambers and valves are working. Your cardiologist can locate areas of poor blood flow and previous damage, and areas that are fibrillating or not contracting properly as well as identify and measure deformations of heart chambers and thickening of heart walls.

Transesophageal Echocardiology, TEE - Atrial Fibrillation test, A-fib, afib, a fib

Screen image: TEE

Transesophageal Echocardiography (TEE)

In this test, a tube with an ultrasound device is passed down through your esophagus. A clear image is captured of the heart muscle and other parts of the heart. As ultrasound waves are directed into the heart, the reflected sound waves are converted into pictures. The TEE is often administered just before an ablation to look for blood clots in your atria. If blood clots are found, anticoagulants are prescribed to dissolve them.

Computerized Tomography (CT) or Magnetic Resonance Imaging (MRI)

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‘Cardiac CT’ uses an X-ray machine and a computer for detailed images of the heart and to make three-dimensional (3D) pictures of your heart and chest. The electrophysiologist uses them to perform catheter ablations inside the heart. A ‘cardiac MRI’ uses radio waves, magnets and a computer to create snapshots and video of your beating heart and can measure the amount of fibrosis (which can be a factor in A-Fib).

Chest X-Ray

X-ray images help your doctor see the condition of your lungs and heart such as fluid buildup in the lungs, an enlarged heart, and other complications of A-Fib.

 Summary

There are several tests your doctor may use to evaluate your A-Fib. A basic understanding of these tests helps you ask informed questions and discuss test results.

 Additional Readings

• Sleep Apnea: Home Testing Now Available  New
• A Primer: Ambulatory Heart Rhythm Monitors
• 
Consumer (DIY) Heart Rate Monitors – Updated
• Understanding the EKG Signal
• The CHADS2 Stroke-Risk Grading System

Last updated: Friday, February 6, 2015

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Return to Treatments for Atrial Fibrillation

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