Drs. Michel Haissaguerre and Pierre Jais from the Bordeaux group (LYRIC) described their use of the vest-like Electrocardiographic Imaging—ECGI—system (from CardioInsight). The system with 256 electrodes is used in combination with rapid CT (Computed Tomography) scans.
The day prior to the patient’s ablation, the ECGI imaging system is used to produce a very detailed 3D color map of the heart to guide the EPs during the patient’s ablation…To learn more, read my 2015 AF Symposium Report−>
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.
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…
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.
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.
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.
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
Obesity 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.
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
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!)
Update the Directory of Doctors & 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).
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.
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.
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?)
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.)
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.
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?
Last updated: Wednesday, February 11, 2015
Technology & Innovations
For a 2014 update about imaging, see my AF Report: Non-Invasive Electrocardiographic Imaging—ECGI—CardioInsight.
Most of the imaging technologies described here are in use today and represent huge advances in patient treatment.
Ordinary ablations use Fluoroscopy, a type of X-ray to see inside and ablate the heart. But it is two dimensional. Intercardiac Echocardiography (Ultrasound) (ICE) is also 2-D but provides excellent anatomic detail and assistance in navigating and positioning the catheter.
Electroanatomic Mapping (EAM) offers a 3-D view both outside and inside the heart in almost real time. New technologies combine both of these technologies. CartoSound (Biosense Webster, Cincinnati, OH) uses a proprietary 3D EAM system and incorporates the information obtained from an intracardiac ultrasound probe to visualize and map the heart. (3-D intracardiac ultrasound probes are being developed which would provide real-time 3-D imaging and navigating.)
From a patient’s perspective, should you try to find a larger facility that has CartoSound rather than one that only uses 2-D fluoroscopy?
Doctors using CartoSound would seem to have better imaging tools to do ablations. But doctors using fluoroscopy also get good results.
Computed Tomography (CT) can also be used to obtain detailed images of the left atrium. Rotational Angiography uses standard fluoroscopic equipment to obtain 3-D CT-like images while rotating around the patient. (Posted: February 19, 2011)
Return to Index of Articles: Research and Innovations
Last updated: Sunday, February 15, 2015
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 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.
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 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.
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.
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.
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 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.)
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.
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.
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 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.
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.
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 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)
‘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).
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.
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.
• 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