ABOUT 'BEAT YOUR A-FIB'...


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

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

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

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"



ABOUT A-FIB.COM...


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


Dr. Michel Haissaguerre

FAQs A-Fib Ablations: The Bordeaux Group

FAQs A-Fib Ablations: The Bordeaux Group 

CHU Hopitaux de Bordeaux logo

“The French Bordeaux Group”

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

Prof. Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation). The Bordeaux group at the Cardiologic Hospital of Haut-Lévêque is still considered one of the top A-Fib centers in the world. (They cured my A-Fib back in 1998. I was their first U.S. patient. Read my story.)

In particular, they are doing cutting edge research using ECGI (CardioInsight) to map and ablate persistent A-Fib. ECGI will probably revolutionize how ablations are mapped and performed.

For the 2016 costs, see my post about David Neth.

How to Contact the Hôpital Cardiologique du Haut Lévêque-(CHU) de Bordeaux 

Online links to University Hospital of Bordeaux, Cardiology and Electrophysiology services (June 2016):

Cardiology and Electrophysiology and Pacing ServicesHead of department: Pr Jean-Michel Haïssaguerre
• Electrophysiology and Ablation, Head of Unit: Prof. Pierre Jais
• Patient Care: Services and Appointment Request – online form (in English)

2010 Article by The Bordeaux Group

Here is something they published in 2010 which explains their methodology and the costs of being treated at Bordeaux. Published as: Are you a good candidate? http://Are you a good candidate?

CATHETER ABLATION OF ATRIAL FIBRILLATION

Currently the only treatments that cure atrial fibrillation (AF) are:

a) Surgery (such as the Cox Maze operation and its variations)
b) Catheter Ablation

The main goals of catheter ablation of AF are to:

1) restore the heart to normal sinus rhythm, thereby eliminating the symptoms of AF.
2) relieve the patient from the associated risks of AF, such as blood clot formation, stroke, cardiac failure, and increased mortality. (It has not been proven that a successful Catheter Ablation will achieve these goals in all A-Fib patients.)

In the catheter ablation procedure a catheter, a soft, thin, flexible tube with an electrode at the tip, is inserted through a large vein in the groin and moved into the heart. This catheter delivers Radiofrequency (RF) energy to cauterize and eliminate the sources or spots in the heart (ectopic foci or wavelet circuits) that are triggering or maintaining the episodes of AF. These sources or spots in the heart are usually found in the pulmonary vein openings. The catheter also makes linear lines or lesions to segment the atrial tissue, thereby interrupting the errant electrical waves responsible for maintaining AF.

This isolation of the pulmonary veins cures the intermittent (paroxysmal) form of AF in 80% of patients (without having to take any medications). An additional 10% of patients are improved—an antiarrhythmic drug keeps them is sinus rhythm without the need for blood thinners.

For patients with permanent or persistent AF (lasting more than 48 hours or who have had Electrocardioversion), isolation of the pulmonary veins is less effective and should be combined with linear lines or lesions. This is because the longer one has episodes of AF, the more the sources or spots in the heart which produce AF signals tend to spread outside the pulmonary veins.

Ablated heart tissue has a tendency to heal itself and recover. For this reason and to increase the success rate to 90%, more than one procedure is required after 1-3 months of follow-up.

PRE-ABLATION MANAGEMENT

For safety reasons (to avoid clot formation during the catheter ablation procedure) the patient should take oral anticoagulation (coumadin, not aspirin) at an optimal therapeutic range (INR 2-3) for at least 1-2 months before the procedure. In addition, a transesophageal echocardiogram should be performed a few days before hospitalization to make sure there are no clots in the heart, particularly in the left atrial appendage. If clots are found, the procedure must be postponed a few days until these clots can be dissolved by blood thinners.

Anticoagulants should be interrupted 48 hours before the day of the procedure. If the patient is taking antiarrhythmic drugs, they should be stopped on admission.

CATHETER APPROACHES

General anesthesia is rarely performed on adult patients, in order to minimize the associated risks of anesthetic drugs. The patient is slightly sedated and a local anesthetic is applied to the groin area. Usually three catheters for mapping and ablation are inserted through one or two femoral veins in the groin and moved up into the heart.

The mapping catheters have multiple electrodes mounted in a longitudinal or circumferential shaft. (Other configurations including investigational designs may be used for individual situations.) The ablation catheter has an irrigated tip to prevent local clot formation and to allow greater energy delivery if needed (at thick parts of the cardiac tissue). To insert these catheters into the left atrium, it is usually required to make a puncture of the transseptal wall between the two upper chambers (atria) at what is called the foramen ovale. After the ablation procedure, this foramen ovale closes back up and heals over. (In 20% of patients this foramen ovale hole never closes up completely and remains open, creating a pathway between the two atria chambers.)

Two or three physicians usually perform the catheter ablation procedure. They are involved in positioning the catheter, and in the collection, analysis and interpretation of heart signals obtained during conventional or computerized mapping.

RF ablation is performed around the openings of the pulmonary veins, one by one or two by two, using a limited level of energy to avoid swelling of the pulmonary vein openings or atrial perforation. Isolation of the pulmonary vein openings is successfully performed in 100% of cases.

In paroxysmal (occasional) AF, PV isolation cures AF in 60-70% of cases. Ablation of the appropriate site in the right atrium (Cavotricuspid Isthmus) is also performed to prevent right atrial flutter. Linear block here is successfully achieved in 99% of cases.

In persistent AF (lasting more than 48 hours or with a history of electrical cardioversion), PV isolation is rarely sufficient. Additional RF applications are required to eliminate spots of AF activity outside the pulmonary veins. In the most resistant cases (usually long lasting AF), linear ablation similar to surgical incision is performed in the left atrium between the two superior PV and/or from the vein to the mitral annulus (mitral “isthmus”). This achieves linear block in 90% of cases. The success depends on achieving continuous and coalescent cauterizing lesions to create a complete barrier. Any gap in the lesion line, even of a millimeter size, allows AF signals to cross thereby keeping the heart in AF. A gap in the lesion line is due either to a too thick atrial wall or recovery of atrial tissue during the 1-4 week healing process following ablation.

Pain and discomfort associated with ablation are controlled by Midazolam and Morphine. Because there are no nerve endings in the smooth tissue of the heart and veins, the pain and discomfort are minimal and usually well tolerated.

DURATION OF OPERATION AND HOSPITAL STAY

The duration of the procedure varies from one to five hours depending on individual conditions:

• the number of ectopic sources in the atrial tissue (outside the pulmonary veins) may require more mapping time.
• successful lineal ablation lines depend on the thickness of the heart wall which varies from one patient to another and can not be precisely determined by pre-ablation imaging.

The end point or goal of the procedure is the achievement of local block in all targeted structures (veins and isthmuses) so that no AF signals travel through the heart. In addition, after the ablation multiple pacing maneuvers are used to try to induce sustained AF. In paroxysmal AF, multiple pacing maneuvers do not induce AF in 90% of cases.

A second procedure may be needed within 3-5 days in 25% of AF patients due to partial recovery of ablated tissue and/or secondary AF sources not ablated in the original procedure. In difficult cases of multiple or unmapable ectopic foci (heart tissue generating AF signals), a second linear ablation may be required in the left atrium.

Patients are hospitalized 4 to 6 days depending on the number of procedures required. Typically they return to the normal care

unit after ablation and are ambulatory 12 to 24 hours later. They are monitored by telemetry during the next 3 days when any recurrence of arrhythmia is most likely to occur. The likelihood of recurrence decreases over the next month.

Patients are usually admitted on Monday and can leave the hospital for the week-end, if there are no complications. They must stay in the region during the week-end and must return the following Monday for outpatient evaluation, which could result in re-hospitalization if needed.

The occurrence of complications may increase the duration of the hospitalization and therefore the cost. In our experience, this happens to 2.5% of patients.

If AF symptoms do not reoccur, patients can return home and resume normal activities. Anticoagulants are recommended for at least 1-3 months after ablation, and can then be stopped if there is no AF or other risk factors. In persistent AF, antiarrhythmic medications are recommended for 1-3 months after ablation to enable the atria to return to normal (this process is called “remodeling.”)

POPULATION OF PATIENTS

Catheter ablation of AF has been performed since 1994 in Bordeaux. As of October 2009, over 6,000 patients have been treated. At least 15 cases of atrial fibrillation or flutter are treated every week. The clinical characteristics of patients cover a wide spectrum of age (15-84 years old, average 52 years old). 78% of patients are male, while 22% are female. 80% have paroxysmal (occasional) AF, 20% have persistent AF. All patients were resistant to or intolerant of an average of 4 antiarrhythmic drugs and experienced at least weekly episodes of AF at their referral.

Some patients had documented pauses in their sinus heart beat after an attack of AF. They were cured by AF ablation, and thus avoided pacemaker implantation. 12% reported a previous embolic event (stroke), most in the circulation of the brain.

In patients with heart failure and permanent AF, the restoration of sinus rhythm (normal heart beat) is associated with a significant improvement of ventricular function in 80% of the patients.

RISKS ASSOCIATED WITH AF CATHETER ABLATION

Currently no one has died of a catheter ablation procedure in our department. Compared to other catheter procedures a 0.1% risk of death is a reasonable estimation.

The other risks of catheter ablation of AF are:

• bleeding in the pericardial sac surrounding the heart and requiring drainage (0.5-1%)
• embolic event (stroke) (0.2%)
• groin access hematoma (bruising) (4%)

There is no risk of sinus node or AV node damage by ablation which would require implanting a pacemaker.
World-wide there have been deaths reported by the use of high wattage catheters (50 watts or higher) creating a fistula (burn through) to the esophagus, usually 2 days after the procedure. We have not observed this complication.
Pulmonary vein narrowing (stenosis), if it did occur, would not usually cause symptoms. Out of 6,000 patients treated in our institution, 7 developed symptoms due to PV narrowing (>70% of lumen [opening] diameter) and required angioplasty and stenting.

The above risks compare very favorably with the risks involved in living with untreated AF. The risks of catheter ablation also compare very favorably with the risks involved in taking antiarrhythmic drugs and anticoagulants.

PROCEDURE COSTS (2010)

This cost is fixed by the public health administration.  The cost for a private service (operators: Drs. M. Haissaguerre/P. Jais/ M. Hocini) is 5000 euros (around $6,000) (hospital and physician charges). The total cost of AF catheter ablation depends on the duration of one’s stay in the hospital, which depends on the difficulty of individual ablation cases.

The typical hospital stay of 5 days with an ablation including pulmonary vein isolation and ablation of the right and left atria would cost about 10,328 euros (around $12,600). One day more or less would be 2044 Euros (around $2,500).

The total costs of a 5 day stay and ablation would be 17,600 euros (around $21,500).
For patients accompanied by a family member and without local accommodations, a meal, bed and breakfast is provided in the same room 27,10 euros/day (around $33.00).

The current waiting time for a procedure is 2 months.

Patients should come with personal clothes, since it is possible to walk outside. Patients are generally expected to wear their own clothes, including pajamas. Since the hospital only provides small towels, you may wish to bring your own towels.

INFORMATION ABOUT THE HOSPITAL

Cardiologic Hospital of Haut-Lévêque is a 300 bed hospital entirely dedicated to medical and surgical cardiology. It is located in Pessac and is a 20 minute drive from the airport, and a 20-30 minute drive from the center of Bordeaux and the TGV station.

Languages spoken: English and Spanish

The web site is: http://www.chu-bordeaux.fr/LES-HOPITAUX-ET-SITES-DU-CHU/Groupe-hospitalier-Sud/Hôpital-Haut-Lévêque/.

If you find any errors on this page, email us. Y Last updated: Monday, July 25, 2016

Return to FAQ Catheter Ablation and Maze Surgeries

2016 AF Report: Predictors of Unsuccessful Ablations: It’s All About Remodeling

AF Symposium 2016

Predictors of Unsuccessful Ablations: It’s All About Remodeling

by Steve S. Ryan, PhD

If someone tells you to “Just live with A-Fib”, or “It’s no big deal,” or “A-Fib’s just a nuisance”, RUN, don’t walk, for a second opinion! Don’t wait—a long enough delay allows atrial remodeling to change your heart and makes it much more difficult to get a successful ablation (i.e., become A-Fib-free).

Predictors of Unsuccessful Persistent A-Fib Ablation

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre, in his presentation “Predictors of Clinical Outcomes in Ablation of Persistent AF Drivers”, found several predictors of unsuccessful ablation outcomes in persistent A-Fib cases. (Drum roll, please.) They are all related to atrial remodeling!

The predictors of unsuccessful outcomes are:

• A-Fib Duration (how long a patient had been in A-Fib prior to ablation)
• A-Fib Cycle Length (the faster the cycle length, the harder to achieve success)
• Number of Drivers (the more drivers mapped, the less chance of success)
• Arial Size (the more the left atrium is extended and stretched, the less chance of success)
• Fibrosis (being in A-Fib normally produces fibrosis)

Dr. Haissaguerre of Central Hospital, Bordeaux, France, used slides to explain his findings. (You may want to read this article together with Dr. Haissaguerre’s other presentation: Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation.)

“Reentries” are Short Lived But Recur in the Same Region

Dr. Haissaguerre showed images of ECGI/ECVUE Cardio Insight mapping done either the day before the ablation or during the procedure. ECGI produces statistical density mapping of “reentries” (rotors) and focal breakthroughs. These reentries are short lived but periodically recur in the same region.

The Number of Driver Regions

The number of driver regions increases with how long a patient has been in persistent A-Fib. In cases of long-standing persistent A-Fib, he has found as many as 7 driver regions.

Fibrosis and Low Atrial Voltage

Dr. Haissaguerre cited the work of Dr. Marrouche which found decreased ablation success with the extent of fibrosis or atrial low voltage. (For more about Dr. Marrouche’s research, see: High Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation)

Characteristics of Reentries (Rotors)

Dr. Haissaguerre discovered several previously unknown characteristic of rotors:

• Driver domains are part of CFAE areas.
• Core trajectories or rotors are anchored at distinct parts of fibrosis.
• There is a strong link of A-Fib drivers to structural heterogeneities (dissimilar parts like the PVs and LAA opening).

For example, 98% of reentries are found at common points like the Left Pulmonary Vein/Left Atrial Appendage (LAA) area. Whereas focal discharges are mainly observed at the PVs (60% of patients), LAA, or Right Atrial Appendage (RAA).

A-Fib Termination Strongest Predictor of Ablation Success

After 12 months, 85% of patients with A-Fib termination were still free from A-Fib. In the small group of patients who did not achieve termination (and were electrically shocked to try to return them to sinus), 63% were A-Fib free after 12 months. The 37% who remained in A-Fib were all patients with persistent A-Fib.

Ablation Works Best if in Sinus Rhythm Before the Ablation

The A-Fib termination rate was 84% in patients in sinus rhythm at the time of the ablation (with an RF delivery time of only 22 minutes). To get persistent patients in sinus before the ablation, they often would be electrocardioverted.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map ATs. Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”. 68% were from driver regions previously ablated. 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

How to Improve Ablation Outcomes

Dr. Haissaguerre stated that the key to improve ablation outcomes is to minimize atrial remodeling by:

1. Ablate earlier (after only a few months of persistent A-Fib, rather than letting patients go into long term persistent).
2. Restore patients to sinus rhythm before the ablation, especially in cases of longer lasting A-Fib.
3. Manage risk factors such as by using preventive drugs.

He showed slides of how flecainide reduced crucial driver regions, and how amiodarone both lengthened cycle length and decreased driver regions.

Dr. Haissaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers in a more specific way than other current approaches
• There’s a strong link of driver locations with structural heterogeneities (anatomical junctions and fibrosis)
• Predictors of clinical outcome—AF Duration, A-Fib Cycle Length, Number of Drivers, Atrial Size, Fibrosis―mainly relate to Atrial Remodeling with obvious practical implications

What Patients Need to Know

Don’t Live in A-Fib! The message for patients from Dr. Haissaguerre’s presentation is fairly obvious—Don’t settle for a life in A-Fib! A-Fib is a progressive disease that usually gets worse over time. It produces remodeling of the left atrium.

Don’t Stay in A-Fib! A delay in treatment makes it much more difficult to have a successful ablation!

Danger of a Fibrotic Heart—Fibrosis: Most of the remodeling effects of living in A-Fib can be corrected or improved by a successful catheter ablation. But not fibrosis! (Which is generally considered permanent and irreversible).

Fibrosis produces collagen and scarring in the heart which is a permanent remodeling effect of A-Fib. Fibrotic tissue is scarred, immobile, basically dead tissue with reduced or no blood flow and no transport function. It results in a loss of atrial muscle mass. Over time it makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems. Read more about fibrosis in my article: A-Fib Produces Fibrosis—Experimental and Real-World Data.

Remodeling Makes Catheter Ablation More Difficult:  A successful ablation is much more difficult when your heart has been remodeled by A-Fib. Patients with Long-standing A-Fib develop as many as seven different driver regions, compared to only two in patients who were in Persistent A-Fib for only a couple of months. Even the ‘great’ Bordeaux group couldn’t cure all of these cases.

Ground-Breaking Discoveries Important for Patients

1―Ablation works best if you are in Sinus Rhythm BEFORE the ablation.
This principle is not yet generally understood and practiced by the EP community. As a patient you should seek out EPs who will try to get you back into sinus before your ablation.

Ask the EP you are interviewing, “Will you try to get me back into sinus rhythm before the ablation?” How will you do this?” They should answer that they will use Electrocardioversion and/or antiarrhythmic drugs to do this, particularly in cases of persistent A-Fib.

For example, one A-Fib patient emailed me that the Mayo Clinic Electrocardioverted her into sinus, then used Tikosyn to keep her in sinus for a month or two before her ablation.

2―A-Fib termination is the strongest predictor of ablation success.
This discovery is very important for patients. Some previous research said that it really didn’t matter if A-Fib terminated during the ablation.

Nevertheless, in Dr. Haissaguerre’s research, 84% of patients with A-Fib termination during the ablation procedure were still free of A-Fib after 12 months.

The Bottom line for Patients

A-Fib termination during the ablation procedure should be the goal of every EP. You should seek out EPs who will make that extra effort (such as replacing the CryoBalloon catheter with a RF catheter to isolate non-PV triggers). All too many EPs aren’t willing or aren’t able to do that.1

Dr. Michel Haïssaguerre

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

Citations for this article

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

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

References    (↵ returns to text)
  1. I recently read an O.R. report where the EP used CryoBalloon ablation on a patient in persistent A-Fib for two months. They successfully isolated the patient’s Pulmonary Vein openings (PVs), but the patient was still in A-Fib. Instead of trying to map and isolate the patient’s non-PV triggers which were still producing A-Fib signals, the EP simply shocked the patient back into sinus rhythm. After a few weeks, the patient was back in A-Fib again. (But to be fair to the EP, sometimes this is successful.)

2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts

AF Symposium 2016

Six Live Catheter Ablations—Watching the Experts

by Steve S. Ryan, PhD

2016 AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

2016 AF Symposium 5-floor-to-ceiling video monitors

Watching LIVE catheter ablations on floor-to-ceiling display screens was one of the most interesting and exciting features of the AF Symposium. “Case Studies: Catheter Ablation for Atrial Fibrillation” featured live streaming video (transmitted via the internet rather than by satellite as in previous years).

The six ablations were streamed live from:Live Streaming Video from 2016 AF Symposium

• Seoul, South Korea
• Munich, Germany
• Bordeaux, France
• Philadelphia, Pennsylvania
• Austin, Texas
• Boston, Massachusetts

A world-class panel of electrophysiologists (EPs) were able to interact with the EPs doing the ablations and ask questions.

The panelists were: Dr. Moussa Mansour (Co-Moderator), Dr. Jeremy Ruskin (Co-Moderator), Dr. Michel Haissaguerre, Dr. Francis Marchlinsk,i Dr. Andrea Natale, Dr. Douglas Packer, Dr. Vivek Reddy and Dr. David Wilber.1

The Live Cases Begin

Seoul, South Korea: 62-year-old in long-standing persistent A-FibLive Seoul S Korea

Drs. Young-Hoon Kim, Jong-II Choi, JaeMin Shim and their colleagues from S. Korea were all wearing radiation glasses. They were doing a very difficult case of a 62-year-old in long-standing persistent A-Fib for 12 years. He had had a previous ablation. But his A-Fib had recurred five months ago.

His PVs were well isolated. They worked on ablating CFAEs, the right atrium, and the septum which was very fibrotic.

Very unusual: an epicardial ablation (outside the heart) to isolate an A-Fib signal from Bachman’s Bundle.
What was very unusual was they performed an epicardial ablation (outside the heart) to isolate an A-Fib signal they found coming from Bachman’s Bundle. (We didn’t get to actually see that, due to the audio problem.)

When they ablated the Left Atrial Appendage, the A-Fib terminated.

What Was Most Impressive

• Ablating from outside the heart. As far as I know, very few EPs do this. Should every EP receive training in ablating from outside the heart? What’s the best way of discovering and mapping A-Fib signals coming from the exterior of the heart, such as from Bachman’s Bundle? (I’ve written the S. Korean EPs to ask them these questions.)

• Successfully ablating and terminating A-Fib in someone who had been in long-standing persistent A-Fib for 12 years. This is usually the most difficult kind of case and the hardest to cure. (Many EPs would consider this long-standing persistent case unfixable and not even attempt a catheter ablation.) It’s no surprise that this was the second ablation for this patient. This case also shows the importance of the Left Atrial Appendage (LAA) in A-Fib ablation.

Munich, Germany: 62-year-old male in long-standing persistent A-Fib and BMI of 35Live Munich Germany

Drs. Isabel Diesenhofer, Felix Bourier and Tilko Reents of the German Heart Center in Munich did an ablation on an unusual case, a 62-year-old male in long-standing persistent A-Fib with a BMI of 35! (Many centers would not accept this patient for an ablation without his first losing weight.)

Dr. Diesenhofer said they don’t use Contact Force sensing catheters because they are too soft. They don’t use TEE but instead use CT to check for clots and to see where the esophagus is in relation to the back of the heart. They perform circumferential PVI.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity. Their goal is to terminate A-Fib during the procedure, but 70%-80% of these cases come back in Atrial Tachycardia (AT). A second ablation is usually more successful.

They found that the fastest frequencies were coming from the patient’s LAA. When they terminated A-Fib, they used adenosine to test for recurrence.

What Was Most Impressive

• I was surprised that they were doing an ablation on someone with a BMI of 35! The chances of recurrence are huge when someone is obese.

• The use of adenosine after termination of the patient’s A-Fib in order to try to re-induce A-Fib and test for ablation integrity and isolation.

• And, as in the live case from South Korea, this case showed the importance of the LAA in A-Fib ablation, particularly in persistent A-Fib.

Bordeaux, France: 40 year old who went directly into persistent A-FibLive Bordeaux France

Dr. Mélèze Hocini, Bordeaux, France worked behind what looked like a Plexiglas screen with arm holes as a protection against radiation. Her patient was unusual in that he was relatively young, 40 years old, who went directly into persistent A-fib without apparently having paroxysmal (occasional) A-Fib first. He had undergone 3 cardioversions. He was symptomatic, especially dyspnea. He had tried Sotalol and Flecainide.

The day before his ablation, he was mapped with the ECGI/ECVUE Cardio Insight vest. Dr. Hocini showed how the vest mapped four basic areas where there were rotors/focal drivers. She had circled each area and gave each one a priority number from 1 to 4 depending on how many rotors/foci there were in each section.

We watched as she ablated the first area. She ablated at 40 watts for 30 or 40 seconds. The LAA had the highest frequency 167. (In general, they try to slow down the frequency to 200 which usually results in termination.)

An important innovation developed by the Bordeaux group is to re-map during the procedure.

An important innovation the Bordeaux group has developed is to re-map during the procedure. Sometimes new signal areas may appear which need to be ablated. Dr. Hocini, re-mapped, but didn’t find any new signal areas. This patient had many CFAEs (70%). The drivers covered 30% of his left and right atria.

Someone mentioned that the Pentaray mapping catheter was faster and provided better definition than ECGI. Non-PV triggers are often found in the septum, anterior left atrium, coronary sinus, and the left and right appendages. The goal is to slow down the frequency and make the signals more organized.

After a visit with the teams in Philadelphia and Austin, the moderators returned to the group in Bordeaux, France.

Eeveryone was relaxing and happy. While we were away, Dr. Hocini had ablated the third area of rotors/foci which terminated the A-Fib and restored the patient to sinus rhythm.Since the patient was already in sinus, Dr. Hocini didn’t ablate the remaining fourth area of rotors/foci.

What Was Most Impressive

• It was simply amazing to see ECGI/ECVUE in action! To me it looked like I was seeing the future of A-Fib ablation. Dr. Hocini seemed almost nonchalant, like she had done this many times before and was confident it would work. Like many great innovations, using ECGI seemed very simple.

Philadelphia, Pennsylvania:  76-year-old woman with hypertension, persistent A-Fib for five years and previous PVILive Philadephia PA

The moderators then switched to Drs. David Frankel, Pasquale Santangeli, and Gregory Supple at the Un. of Pennsylvania in Philadelphia. They were ablating a 76-year-old woman with hypertension who had been in persistent A-Fib for five years. (Usually a more difficult case.) She had had a Cardioversion in 2014. She was on amiodarone but was still severely symptomatic.

In their experience, ablating only the PVs returns patients to sinus in 80% of all types of A-Fib. They find non-PV triggers in many different sites in the left and right atria. Their protocol is to do a PVI, cardiovert, ablate, then use isoproterenol to induce or re-induce A-Fib triggers.

…a somewhat unusual strategy called “empirical” ablation…Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

This patient also had had a previous PVI, but two of her PVs were re-connected and needed to be ablated. She was restored to sinus rhythm. They then used isoproterenol to try to re-induce A-Fib.

They also employed a somewhat unusual strategy called “empirical” ablation. From their experience, they know that certain sites in the atria tend to produce non-PV A-Fib signals. Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

What Was Most Impressive

• “Empirical” ablation (ablating areas known to produce A-Fib signals even though the patient is no longer in A-Fib) is a somewhat controversial strategy. Some would say one shouldn’t scar or burn the heart unless those areas are actually producing A-Fib signals or potentials. Scarring does damage heart tissue. Personally, I would prefer to have them ablate these “empirical” sites as long as they are in my heart anyway.

• In contrast with the Munich, Germany case, the EPs in the Un. of Pennsylvania used isoproterenol to try to re-induce A-Fib rather than adenosine.

Austin, Texas: 83-year-old woman in long-standing persistent A-FibLive AUSTIN TX

The moderators then switched to Drs. Rodney Horton, Amin Al-Ahmad, and J. David Burkhardt at the Texas Cardiac Arrhythmia Center in Austin, TX. They didn’t use any fluoroscopy during their ablation and weren’t wearing the standard-issue lead vests to protect from radiation. They used ICE for navigation.

Their patient was an 83-year-old woman in long-standing persistent A-Fib. Even though she was very symptomatic, she was very active and was scheduled to be married in a couple of weeks. She had been on amiodarone and had failed cardioversions. She had a lot of severe scarring.

They stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA.

They cardioverted her two times without success. After their first ablation, they used isoproterenol to check for re-connection. Two of the PVs had reconnected and had to be re-isolated. Their next step was to isolate the LAA. But they stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA. This patient knew that she could lose her LAA, that later they may have to physically remove it, and that this might affect her.

She still wanted it done so that she could be restored to sinus rhythm. For her it was better long term to be free of A-Fib than to retain a LAA.

They did electrically isolate her LAA and restored her to sinus rhythm, which she hadn’t been in in many years.

What Was Most Impressive

• Though we had seen this last year in the live cases, it was still something of a shock to see EPs, nurses and staff not wearing any protective gear against radiation. (When I visited an A-Fib lab to watch an ablation, I had to wear a very heavy lead vest and other protective gear.) They use ICE instead of fluoroscopy (X-ray) to manipulate the catheters.

• You will notice that this is the third live case emphasizing the importance of the LAA, particularly in persistent A-Fib. They discussed with this patient the possibility that she might lose her LAA. But like most A-Fib patients, she was willing to take that risk to be free of A-Fib

Boston, Massachusetts: 65-year-old male with atypical FlutterLive BOSTON MA

The moderators then switched to Dr. Kevin Heist at Massachusetts General Hospital in Boston. He was working on a case of atypical Flutter. A 65-year-old male patient had been symptomatic for many years. He had tried flecainide. In 2003, he had a PVI. Then in 2010 he had to have a re-do which kept him in sinus rhythm for 5 years. In 2015 he had a cardioversion but still had atypical flutter. His ejection fraction was a very good 75%, but he had mild left atrial enlargement. They found that his PVs and posterior atrium wall were still well isolated.

Biosense Webster PentaRay catheter

The Biosense Webster PentaRay catheter

They demonstrated how to use the PentaRay NAV mapping and ablation catheter (Biosense Webster) to very rapidly map the atrium. It uses a multi-electrode mapping technology. The five branch star design has branches that are soft and flexible so as not to damage the heart surface.

Through pacing, Dr. Heist found a Mitral Annulus Flutter, which he ablated. This terminated the Atrial Tachycardia and restored the patient to sinus.

What Was Most Impressive

• It was fascinating to watch the PentaRay catheter rapidly move by itself over the heart. It kind of looked like a spider crawling along inside the heart. It was amazing how fast the PentaRay catheter reproduced and mapped the heart automatically in high resolution. Very few moves were necessary to map the whole left atrium.

• Is the PentaRay NAV mapping catheter better than the FIRM or ECGI/ECVUE systems? Should one seek out a center using the PentaRay catheter? Right now we can’t say for sure. As far as I know, there haven’t yet been any comparative studies of the PentaRay mapping catheter compared to FIRM or ECGI. Most likely it will eventually be used in combination with FIRM or ECGI. It seems like an important tool and advance in mapping.

That’s a WrapThats a Wrap on TV monitor 215 x 200 pix at 300 res

The co-moderators, Dr. Moussa Mansour and Dr. Jeremy Ruskin (both from Mass. General Hospital, Boston,MA) did a good job moving the program along and kept the interactions with the EP labs personnel on point.

It’s awesome to watch the world’s best electrophysiologists restoring patients to normal sinus rhythm and making them A-Fib-free.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

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

References    (↵ returns to text)
  1. An audio problem caused a delay at the start of the program. During the wait, the panelists spoke about their work with persistent A-Fib. Dr. Marchlinski said that at the Un. of Pennsylvania 11% of male patients have non-PV triggers while 16% of females have them. (However, he uses a more conservative, stricter definition of an A-Fib trigger.) Whereas Dr. Reddy said that at Mount Sinai Hospital, 30% have non-PV triggers.

    Dr. Vivek Reddy considers the mapping and ablation of non-PV triggers to be the next step in the evolution of catheter ablation of A-Fib. (This is perhaps the most important statement made at this AF Symposium.)

    Both Dr. Reddy and Dr. David Wilber (Loyola, IL) use the FIRM mapping system among other mapping strategies. (ECGI/ECVUE is not currently available in the US.)

Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation

AF Symposium 2016

Bordeaux New ECGI Ablation Protocol—Re-Mapping During Ablation

by Steve S. Ryan, PhD

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

Why should patients be interested in a new mapping and ablation technique that isn’t yet available worldwide and in the US?

Why ECGI/ECVUE is Important

ECGI/ECVUE is probably the most significant, game changing improvement in treating A-Fib (along with Contact Force sensing catheters), particularly for people with persistent A-Fib.

ECGI will not only change the ways mapping and ablations are done, but possibly how you and I are examined and diagnosed in our doctor’s office.

Image a Future Physical Without an EKG

Imagine when you go in for a physical that, instead of getting an EKG, you simply put on an ECGI vest which tells the doctor where and how many A-Fib producing potentials you have in your heart, all without you having to be in A-Fib. Admittedly, this is pie-in-the-sky speculation right now. But the ECGI vest has tremendous potential to change the way A-Fib is diagnosed and treated.

Dr. Michel Haissaguerre & New Uses of ECGI/ECVUE

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France presented new developments in how the Bordeaux group now uses ECGI/ECVUE Cardio Insight body surface mapping for persistent A-Fib. His talk was entitled “Monitoring of AF Drivers During Catheter Ablation for Persistent AF.” (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging [ECG]). See also How ECGI Works.)

Patient Prep with the ECGI Vest

Typically, the day before an ablation, a technician (it doesn’t have to be the EP ablationist) uses a ECGI vest to map and identify sites in the heart producing A-Fib signals (rotors and focal sources). The next day, using this map combined with a CT scan which produces a very detailed 3D color map of the heart, the EP ablates and isolates these sites.

What’s New: Bordeaux Group Also Re-Maps Using the ECGI Vest

What’s brand new about how the Bordeaux group is using ECGI is that, if a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest. This often reveals missed, changed or new A-Fib drivers. They then ablate/isolate these regions.

If a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest.

The ideal or goal is for A-Fib to terminate into sinus rhythm or Atrial Tachycardia (AT). Atrial Tachycardia (a heartbeat that is in sinus rhythm but faster than normal) can then also be mapped and ablated into Normal Sinus Rhythm (NSR). (Atrial Tachycardia, for the average persistent patient, feels a lot better than being in A-Fib.)

If after re-mapping and ablation, the patient is still in A-Fib, they use Electrocardioversion to try to shock the patient back into sinus.

See the AF Symposium Live Case Presentations: Dr. Mélèze Hocini of the Bordeaux group ablated a 40-year-old male with persistent A-Fib. She found four areas of rotor/focal activity in his heart. After ablating the third area, the patient’s persistent A-Fib terminated. Dr. Hocini did not have to re-map or ablate the fourth area.)

Slides of Before and After ECGI Ablation

Dr, Haissaguerre showed slides of before and after an ablation using ECGI. Ablation at a driver region transformed rapid, complex signals into slower, organized signals.

In the AFACART study in which eight different centers used the ECGI system, ablations in driver regions varied from 38 to 98 minutes of cumulative RF energy delivery time per center despite similar patients and targets (indicating the current lack of standardized ablation techniques). (For more on the AFACART study, see AF Symposium 2015: AFACART Clinical Trial.)

Persistent A-Fib Case: In the case of a 48-year-old female in Persistent A-Fib for four months, four target areas were identified: the inferior Left Atrium (LA), the LA Septum, the anterior of the LPV (Left Pulmonary Vein) to the LAA, and the posterior area of the RPV (Right Pulmonary Vein). (They divide the left and right atria into seven general physical areas.) A-Fib continued after these driver areas were ablated. On re-mapping, the septum area was found to be still active. After 2 more minutes of RF delivery to that septum area, A-Fib terminated into normal sinus rhythm.

Ablation Failure From Thicker Atrial Tissue?

Dr. Haissaguerre pointed out that ablation failure happens particularly in the right and left atrial appendages because of thicker atrial tissue. He showed a slide where he ablated one driver area, then six months later ECGI showed a new driver region at the LAA ridge.

Right Atrium Drivers Reduced After Left Atrium Ablation

Next, he showed slides where the ECGI mapping system initially showed driver activity in the Right Atrium (RA). But after Left Atrium (LA) ablation, this driver activity was greatly reduced. He suggested that RA drivers might mirror or be a projection of LA drivers.

Right Atrium drivers might mirror or be a projection of Left Atrium drivers.

(This is a new research finding that may be very important and may change the way the right atrium is ablated in persistent A-Fib cases.)

ECGI After Prior Extensive PVIs

Dr. Haissaguerre showed slides of patients who had had two or three prior PVIs. ECGI clearly showed where there were still driver regions. Each patient’s persistent A-Fib was terminated into normal sinus rhythm.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map Atrial Tachycardias (AT). Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”; 68% were from driver regions previously ablated; 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

Limitations of ECGI NonInvasive Driver Mapping

According to Dr. Haissaguerre:

• Body filtering (ECGI) may miss small local AF Signals, while showing the main propagating waves in a panoramic scope
• Extensive ablation may affect egm (electrogram) quality and analysis
• Besides ‘drivers’, other mechanisms of AF perpetuation may coexist, particularly in longer lasting (>1 year) AF

Dr. Haissaguerre’s Conclusions

• Remapping can confirm elimination or persistence of drivers or show new drivers (requiring further ablation)
• This dynamic information will probably increase the rate of AF termination
• Further improvement expected with rapid mapping of Atrial Tachycardias

What Patients Need to Know

The ECGI/ECVUE Cardio Insight body surface mapping seems like a major improvement and development, particularly for patients in persistent A-Fib, usually the hardest to cure.

ECGI is probably the most significant, game changing improvement in the treatment of A-Fib (along with Contact Force sensing catheters).

This ECGI system is being carefully developed in eight centers in Europe (AFACART clinical trial). It was recently purchased by Medtronic and is headquarted in Dublin, Ireland.

(No one at the Medtronic booth at the AF Symposium exhibit hall could tell me when the ECGI system will be available for examination and use in the US and worldwide. I’ll update this report when I know.)

Re-Mapping a Major Improvement in ECGI: We’re grateful to Dr. Haissaguerre and the Bordeaux group for developing the technique of re-mapping during an ablation. It’s certainly a major improvement in what was already a very good mapping and ablation system.

Mapping and Ablating Atrial Tachycardias (ATs): From a patient’s perspective, it’s great to know that ECGI can be used to identify and ablate atrial tachycardias (fast heart rates).

A-Fib termination can result in normal sinus or ATs which are a form of sinus rhythm. For most people, ATs are certainly better than being in A-Fib. But they can be annoying and disruptive. It’s good to know they can be mapped and ablated just like A-Fib signals.

ECGI May Miss Small Local ATs and A-Fib Signals: ECGI isn’t perfected yet. Dr. Haissaguerre showed that many of the local ATs found came from driver regions previously ablated.

DR. MICHEL HAÏSSAGUERRE

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

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

Primary Care Doctor Ignorant of Electrophysiology?

I recently received an email from an A-Fib.com reader relaying a unexpected experience and asking my advice:

“When I was talking with my primary care doctor, he wasn’t sure what an ‘Electrophysiologist (EP)’ was or even if they were regular doctors. I had to explain how an Electrophysiologist (EP) is a cardiologist who specializes in heart rhythm problems, and is board certified in internal medicine, cardiology, and more importantly in Electrophysiology.

No wonder they didn’t refer me to an EP.

How widespread is this problem? How can we make the A-Fib community more aware of this?”

For decades, drug therapy was the traditional treatment for A-Fib. Today, it’s still common for a primary care doctor or general practitioner to treat A-Fib patients with rate and rhythm control medications rather than referring them to a heart rhythm specialist.

Treatment alternatives didn’t come until the pioneering research and procedures first developed by Dr. James L. Cox and Dr. Michel Haissaguerre (the Cox Maze surgeries in 1987 and pulmonary vein catheter ablation in 1996, respectively). Still, it has taken twenty years for Catheter Ablation procedures to be accepted as a first-line therapy for A-Fib patients (see the AHA/ACC/HRS. 2014 Guideline for the Management of Patients With Atrial Fibrillation).

On the A-Fib.com website, one of our core tenets is to encourage patients to seek the advice of one or more heart rhythm specialists (a cardiologist who specializes in heart rhythm problems is called an electrophysiologist or EP).

A-Fib is an Electrical Problem. While most people have heard of a cardiologist, they aren’t familiar with the term ‘electrophysiologist’ (EP) or what they do. They don’t know that cardiologists focus on the vascular function of the heart while electrophysiologists (EPs) specialize in the electrical function (think ‘plumber’ of the heart vs. ‘electrician’ of the heart).

Back in 2002 when we started the A-Fib.com website, our list of recommended electrophysiologists and medical centers offering catheter ablations to A-Fib patients had only seven facilities listed. Today, our Directory of Doctors and Facilities lists over 1,800 electrophysiologists and medical centers.

You can find an Electrophysiologist (EP) on your own; refer to our Finding the Right Doctor page and related readings; look for ‘board certified’ in ‘Clinical Cardiac Electrophysiology.

Speak out on A-Fib Forums: It is vital for A-Fib patients to seek out a heart rhythm specialist, i.e. an electrophysiologist (EP). (I often feel like John the Baptist in the desert trying to spread the word about EPs.) To help, you can post your comments and start a discussion on one or more of the online Atrial Fibrillation Support groups, groups such as Daily Strength Atrial Fibrillation Support Group and Facebook Group: Atrial Fibrillation Support Forum.

For a list of recommended groups see our page: A-Fib Online Discussion Groups and Message Boards.

References for this article

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