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Aging

In your 80s? Are You Doomed to a Life in A-Fib or Can You Still Have a Catheter Ablation?

If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. You most likely can still have a catheter ablation. The research by Dr. Pasquale Santangeli is very hopeful and encouraging.

Study of Octogenarians Who Had a Catheter Ablation (PVI)

Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.

 If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs.

• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).

• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.

• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)

In practice, octogenarians have been largely excluded from clinical trials of catheter ablation. Current guidelines are also very conservative, because there has been a lack of adequate clinical studies in this area. Dr. Santangeli’s report is a step in the right direction.

When Old Isn’t Necessarily Old

In the real world old isn’t necessarily old. People in their 80s may indeed have ‘excellent functional and health status” which would make them good candidates for a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

You can still have a catheter ablation but you need to find an EP Experienced in Non-PV Triggers.

After all, a catheter ablation is a non-invasive procedure. It isn’t like open heart surgery which is incredibly taxing and physically demanding. You don’t have to be a ‘Johnny Atlas’ muscleman to have a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

In your 80s? Find an EP Experienced in Non-PV Triggers

If you’re in your 80s, you most likely can still have a catheter ablation. But, you need to find the right electrophysiologist (EP).

Make sure you select an EP with a proven track record of finding and isolating non-PV triggers. (Dr. Santangeli’s research found that octogenarians have more non-pulmonary vein trigger sites.) Some EPs can’t or won’t make the extra effort to map and ablate non-PV triggers.

(I’ve read O.R. reports where the patient was still in A-Fib after the EP had ablated their PVs. Instead of trying to map and ablate non-PV triggers, the EP simply electrocardioverted [shocked] the patient back into sinus rhythm. After a short time, the patient went back into A-Fib.)

Questions to Ask a Prospective EP

When interviewing a prospective EP, ask:

 “What do you do if I’m still in A-Fib after you’ve ablated my pulmonary veins?” (You want a reply such as “I use mapping to search for non-PV triggers in other areas of the heart”.)

We are indebted to Dr. Santangeli and his colleagues for showing that octogenarians can have a successful, safe ablation, and shouldn’t be excluded from a catheter ablation simply on the basis of their age.

To learn more: read my related article: FAQs A-Fib Ablations: Is 82 Too Old for a PVA?  

References for this article
Radiofrequency catheter ablation is safe and effective in the octogenarian patient with atrial fibrillation. Cardiac Rhythm News. 25 Apr 2012. URL: http://www.cxvascular.com/crn-latest-news/cardiac-rhythm-news—latest-news/radiofrequency-catheter-ablation-is-safe-and-effective-in-the-octogenarian-patient-with-atrial-fibrillation.

Catheter Ablation of Atrial Fibrillation in Octogenarians: Safety and Outcomes. Journal of Cardiovascular Electrophysiology, Volume 23, Issue 7, pp. 687-693, July 2012.  DOI: 10.1111/j.1540-8167.2012.02293.x

In Your 80s? Are You Doomed to Live In A-Fib?

A-Fib is age related. In particular, more people in their 80s are developing A-Fib.

Yet many A-Fib centers have a policy of not performing a catheter ablation on anyone 80 years old or older. But these are often the patients who need a PVI the most. Up to 25% of strokes occurring in octogenarians can be attributed to A-Fib.

It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older.

It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older. Isn’t this age discrimination? Why exclude octogenarians from a potentially curative treatment like catheter ablation (PVI)?

Study of Octogenarians Who Had a Catheter Ablation (PVI)

Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.

• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).

• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.

• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)

What Patients Need To Know

If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. Dr. Santangeli’s work is very hopeful and encouraging. …Continue reading…

A-Fib Hospitalizations Up Sharply since 2000

A-Fib Hospitalizations Up Sharply since 2000

A-Fib admissions up 23%

Research Findings

A-Fib Hospitalizations Up Sharply since 2000

US researchers found a 23% jump in overall hospitalizations due to A-Fib in the decade 2000 to 2010, and the costs of treating A-Fib rose 24%.

But the number of A-Fib patients dying in hospital decreased. There was a 29.2% drop in the mortality rate, which fell from 1.2% to 0.9%.

The study’s data was obtained from the ‘Nationwide Impatient Sample’ of 3.9 million medical records. The study author was Dr. Nileshkumar Patel at Staten Island University Hospital in New Your City.

Some of this increase in hospitalizations was due to the increase in US population (particularly older Americans). Older patients drove most of the total hospitalization increase.

Among people over the age of 80, the annual A-Fib hospitalization rate jumped from 9,361 to 11,045 million per year. Hospitals in the South had the highest percentage of A-Fib admissions (38%), while those in the West had the lowest (14%).

But part of the decade’s 23% increase is due to A-Fib co-morbidities (simultaneous presence of two chronic diseases or conditions). Patients with A-Fib often have other illnesses, too. The most common co-morbidities were hypertension, which was observed in 60%, diabetes (21.5%), and chronic pulmonary disease (20%).

Editor’s Comments:
This is not surprising news, but it is somewhat alarming. One of the reasons for the hospitalization increase is both doctors and patients are more aware of A-Fib and the health risks than they were in previous decades. (In 2009, the US Congress declared September as Atrial Fibrillation Awareness month.)
The good news is that fewer A-Fib patients are dying in hospitals probably due to better training and treatment options. But hospitalizations are expected to rise as the US population over age 80 increases from an estimated 11.4 million in 2008 to 19.5 million in 2030. It’s projected 1 out of 10 people over 80 will develop A-Fib. That’s nearly 2 million new patients with A-Fib!
The authors of this study point out that this “will lead to an enormous increased burden on the public health system and associated cost of care.” There will certainly be a lot more hospitalizations for A-Fib.
No Mention of Catheter Ablation: The authors discussed interventions for controlling costs such as the drug therapies of rate control vs. rhythm control. but did not mention catheter ablation (or Maze surgeries).
But the best and most cost-effective way to keep A-Fib patients out of the hospital is to make them A-Fib free, and also to take care of health conditions such as hypertension, obesity, diabetes, sleep apnea, smoking, and binge drinking. (Many EPs today recognize the importance of these health problems and how much they contribute to A-Fib. They require their patients to deal with these health problems before they can get a catheter ablation.)
From a public health perspective, shouldn’t we as citizens focus our efforts on strategies and treatments that offer the hope of a cure for A-Fib? That’s the best way to keep people out of hospitals.
References for this Article
• Smith, Andrew. Hospitalizations Due to Atrial Fibrillation Up Sharply since 2000. HCPlive.com. May 26, 2014. http://www.hcplive.com/articles/Hospitalizations-Due-to-Atrial-Fibrillation-Up-Sharply-since-2000

• Preidt, Robert. More Americans Hospitalized for Irregular Heartbeat, Study Finds. HealthDay News. May 19, 2014. http://consumer.healthday.com/cardiovascular-health-information-20/heart-attack-news-357/atrial-fib-hospitalizations-circulation-release-batch-1198-687878.html

• Patel, N.J. et al. Contemporary Trends of Hospitalization for Atrial Fibrillation in the United States, 2000 Through 2010. Circulation. 2014; 129:2371-2379. http://circ.ahajournals.org/content/129/23/2371.abstract?sid=af00468a-8d6c-406d-b9a9-719b4abb307c doi: 10.1161/CIRCULATIONAHA.114.008201

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Last updated: Sunday, February 15, 2015

FAQs Understanding A-Fib: Questions from Patients

FAQs Understanding Your A-Fib A-Fib.comFAQs: Understanding Atrial Fibrillation

Atrial Fibrillation patients often have loads of “Why?” and “How?” questions. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1.  Causes: Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?”

Related Question: Why do older people get Atrial Fibrillation more than younger people?”

Related Question: “What causes Paroxysmal A-Fib to turn into Persistent (Chronic) A-Fib?”

Related Question: “A-Fib and Flutter—I have both. Does one cause the other?”

2.  Hereditary: Is my Atrial Fibrillation genetic? Will my children get A-Fib too?”

3.  PSVT: Is Atrial Fibrillation (A-Fib) different from what doctors call Paroxysmal Supraventricular Tachycardia?”

4.  Adrenergic/Vagal: What is the difference between “Adrenergic” and “Vagal” Atrial Fibrillation? How can I tell if I have one or the other? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?”

5.  Heart Condition: “How do I know if I have an enlarged left atrium and what does it mean, if it is? What is the size of a normal left atrium? 

Related Question: Fibrosis:How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?”

Related Question: Stiff Heart: I’ve heard about ‘stiff heart’ or diastolic dysfunction. When you have A-Fib, do you automatically have diastolic heart failure? What exactly is diastolic dysfunction?”

6.  Stem Cells:I’ve read about stem cells research to regenerate damaged heart tissue. Could this help cure A-Fib patients?”

7.  EF: What is the heart’s ejection fraction? As an A-Fib patient, is it important to know my EF?”

8.  Anesthesia:I read that the local anesthesia my dentist uses may trigger my A-FibWhy is that?”

9.  Treatment Options:My surgeon wants to close off my LAA during my Mini-Maze surgery. Should I agree? What’s the role of the Left Atrial Appendage?”

Related Question: “My cardiologist recommends a pacemaker. I have paroxysmal A-Fib with “pauses” at the end of an event. Will they stop if my A-Fib is cured? I am willing, but want to learn more about these pauses first.”

Related Question: My EP won’t even try a catheter ablation. My left atrium is over 55mm and several cardioversions have failed. I am 69 years old, in permanent A-Fib for 15 years, but non-symptomatic. I exercise regularly and have met some self-imposed extreme goals. What more can I do?

10.  Cure Rate: I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate.”

If you find any errors on this page, email us. Y Last updated: Saturday, June 16, 2018

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FAQs Understanding A-Fib: Aging into A-Fib

 FAQs Understanding A-Fib: Aging

FAQs Understanding Your A-Fib A-Fib.com“Why do older people get Atrial Fibrillation more than younger people?”

We know that those over 60 years old are in the higher risk group for developing A-Fib. This may be related to what is called “Interstitial Fibrosis” which is often part of the aging process.

The Pulmonary Vein openings (where most A-Fib signals originate) sometimes become fibrous as we age. The Pulmonary Vein openings are similar in structure and have similar smooth muscle tissue as the Sinus and AV Nodes which generate your normal heart beat signal. The Pulmonary Vein openings are electrically active in the heart like the Sinus and AV Nodes but usually beat in sync with them. When the Pulmonary Vein openings become fibrous, they tend to beat out of sync with the Sinus and AV Nodes which results in A-Fib.

Please be advised that the above statement is an observation, an attempt to explain, rather than a medical fact. Further research is necessary to confirm this observation.

Go back to FAQ Understanding A-Fib
Last updated: June 18, 2018

A-Fib Producing Spots Outside the Pulmonary Veins – 2014 Boston AF Symposium

Vivek Reddy Mt Sinai Hospital

Dr Vivek Reddy Mt Sinai Hospital

2014 Boston AF Symposium

A-Fib Producing Spots Outside the Pulmonary Veins

Report by Dr. Steve S. Ryan, PhD

Dr. Vivek Reddy of Mount Sinai Hospital in New York gave a presentation entitled “What is the true rate of Non-PV triggers?”

Why do ablations fail?

Dr. Reddy posed the question, ‘Why do ablations fail?’ The most common reason is a gap in an ablation lesion. Dr. Reddy showed slides of a typical wide area antrum isolation ablation with remarkably precise point-by-point burns. But there was a slight gap which let A-Fib signals escape from the pulmonary veins into the rest of the heart. But Non-PV triggers can also cause ablation failure.

Dr. Reddy asked the BAFS attendees:

“What is the rate of non-PV triggers after an extra-ostial PV isolation procedure?”

The choices ranged from 5% to over 25%.

The actual rate of non-PV triggers is approximately 23%.

Carina important origin of A-Fib triggers

Dr. Reddy showed how the ‘carina’ (the area in the heart between the left and right pulmonary vein openings) is often a source of A-Fib triggers and of recurrence after an ablation. According to the study cited, “the carina region (has an) apparently unique electrical behavior.” To effectively isolate PVs, it is frequently necessary to target within the circumferentially ablated veins in the carina region, even though there is a risk of stenosis.

Where are the non-PV triggers usually from?

In an older study of 248 Paroxysmal A-Fib patients, 28% had non-PV triggers. (These earlier studies often used segmental or ostial isolation and weren’t as durable as later procedures.) The most common locations were:

▪  LA Posterior Free Wall: 38% ▪  Superior Vena Cava: 37% ▪  Crista Terminalis: 13.7% ▪  Ligament of Marshall: 8.2%

(In this study, the Carina area and newer areas of interest such as the Left Atrial Appendage were not mentioned)

Left Atrial Appendage (LAA)

In a study of nearly 4,000 A-Fib patients that looked at redo procedures for paroxysmal, persistent and long-term persistent A-Fib, 27% had LAA firing (the LAA is the source of arrhythmia), much more in the long-term persistent (58%) compared to paroxysmal (18%). Most wound up having a LAA isolation procedure. (Many centers, as part of their protocol, now routinely first look at the LAA after isolating the PVs. See Bordeaux Five-Step Ablation Protocol for Chronic A-Fib.)

Age Dependent

Paroxysmal patients over 80 years old had many more non-PV triggers than other patients.

Recurrence Associated with Predominately Non-PV Triggers

In a study of 197 paroxysmal A-Fib patients from 2009 to 2012 using irrigated tip RF catheters and extraostial PV isolation, there were non-PV triggers in 23.7% of patients. In patients who had recurrence, 70.8% had non-PV triggers.

 In patients who had recurrence, 70.8% had non-PV triggers.

Editor’s Comments:
Dr. Reddy’s research is important for EPs who will now look more closely at areas like the Carina and the Left Atrial Appendage to find and ablate/isolate non-PV triggers.
What does Dr. Reddy’s research mean for patients? Since 23% of A-Fib ablation triggers are found in other areas of the heart than the pulmonary veins, a simple Pulmonary Vein Isolation (PVI) or Maze surgery may not be enough to cure your A-Fib.
One of the most important findings of Dr. Reddy’s research is that recurrence (a failed ablation) is most often associated with non-PV triggers (70.8%). When searching for the right Electrophysiologist (EP) to do your ablation, they have to have experience in tracking down these non-PV triggers. When interviewing EPs, maybe one of the questions needs to be “How often do you find non-PV triggers? How do you track them down and ablate them?”
You should probably avoid any EP who only isolates the PVs. [I’ve read Operating Room reports from EPs who only do a PVI, never look for non-PV triggers, and don’t terminate the A-Fib by ablation. Instead they shock the patients back into sinus rhythm, then load them up with powerful but toxic antiarrhythmic meds like amiodarone. This usually doesn’t work.)
If you are considering (Wolf) Mini-Maze surgery, be aware that most Mini-Maze surgeries only isolate the PVs. Your chances of having non-PV triggers which a Mini-Maze surgery will not ablate/isolate are approximately 23%. That translates to at least a 23% chance of failure.
If you have non-PV triggers or A-Fib/Flutter coming from the right atrium, most Maze surgeries won’t make you A-Fib free. Surgeons currently do not access the right atrium during most Maze surgeries. To take care of these other A-Fib spots, you will have to schedule a catheter ablation.
References for this article
Valles, E. et al. Localization of Atrial Fibrillation Triggers in Patients Undergoing Pulmonary Vein Isolation. Journal of the American College of Cardiology. Vol. 52, No 17, October 28, 2008, Pages 1413-1420. DOI: 10.1016/j.jacc.2008.07.025

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Last updated: Friday, August 28, 2015 

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