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Western Atrial Fibrillation Symposium

My 2nd Report: More from the 2016 Western AF Symposium

Second in a series By Steve S. Ryan, PhD

This is my second report on The Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Look for my first report with 9 brief summaries.

Introduction: After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant information was provided (sometimes by the same presenters). In all, there were 53 scheduled presentations of 15 minutes each.
This time I cover 6 brief summaries of technical presentations.
Skiing in Park City, UT

Park City, UT, site of the 2016 Western AF Symposium

A New Ablation Parameters Concept for an Accurate Lesion Assessment During AF Ablation

Dr Moussa Mansour discussed the Biosense Webster’s Thermocool SmartTouch irrigated tip ablation catheter with force sensing technology and the St. Jude Medical’s TactiCath (Endosense) contact-force sensing ablation catheter. Each provides the operator with force and contact info which both lowers PV reconnection and the need for repeat ablations.

The newer contact force sensing catheters will also integrate not only force and contact info but also duration, power, catheter stability, and temperature to accurately predict lesion depth and quality. In one system, lesion tags will be automated. A (completed) lesion tag will only be displayed if the lesion meets pre-set criteria.

I’d like to put together a ‘Steve’s List’ of EPs using contact force sensing catheters, but I can’t get the information from the manufacturers (Biosense Webster and St. Jude Medical).
Contact force sensing catheters are a huge improvement in RF ablation. You should insist on an EP who uses contact force sensing catheters. Ask your EP office staff if they use contact force sensing catheters. If they don’t know what you are talking about, contact another EP.

Rotors in Human AF: Multicenter Experience

Dr. Gary Tomassoni has been using the FIRM 64 electrode basket mapping catheter to perform ablations. He uses FIRM-guided ablation in conjunction with PVI.

In his experience rotors are stable and are critical to success. He tailors his ablations to the location of the rotors which he uses as the anchors of the procedure. He starts with the right atrium, then moves to the left. In general, termination during the procedure works better than having to electrocardiovert the patient back to normal sinus rhythm.

Anticoagulation During AF Ablation: Multi-Center Experience

When using an open irrigated RF catheter along with warfarin, Dr. Natale’s group reported no stroke/transient ischemic attacks in 2,618 ablation patients even though they had a higher prevalence of nonparoxysmal A-Fib and higher CHADS2 scores. [In previous studies, patients with Persistent/Permanent A-Fib were more likely to develop strokes during RF ablation.] In a smaller study, uninterrupted rivaroxaban (Xarelto) during RF ablation reduced silent cerebral ischemia as detected by dMRI.

In a small study of apixaban (Eliquis) compared to warfarin, there were no strokes/TIAs and no silent cerebral ischemia in the apixaban group.

Dr. Natale concluded that uninterrupted Xarelto and Apixaban seem to provide the same protection as uninterrupted warfarin, though more data and studies need to be done to verify their safety.

He stressed that anticoagulation should be started before the transseptal puncture rather than after. [From the O.R. reports I’ve read, this doesn’t seem to be normal practice.]

Fiber Optical Balloon: Experience and Long-Term Outcome Data

Dr. Edward Gerstenfeld showed video and slides of the CardioFocus Laser Balloon Catheter (not yet approved for use in the US). In addition to the operator being able to see directly where he is ablating through optical fiber, the balloon is compliant and can adapt to the individual contours of the pulmonary vein. 99% of PVs were isolated with the balloon alone.

Results are similar after 1 year to irrigated RF ablation. Over 7,000 ablations using the Laser Fiber Optic Balloon catheter have already been performed in Europe. See my article on Laser Balloon Catheter.

Long Term Follow Up on Patients with Failed Ablation of AF

Dr. David Callans pointed out that patients with a successful A-Fib ablation do better than A-Fib patients without ablation in terms of three-year mortality and stroke. A study of 3,355 patients at 3 centers over four years who had a successful A-Fib ablation, found those patients had very little stroke risk even compared to patients still taking anticoagulants.

Of patients not taking anticoagulants who had a CHADS2 risk score of greater >2, none had an ischemic stroke (A-Fib related stroke). Whereas in the group still taking anticoagulants, 2% had a hemorrhagic stroke vs 0.04% of those not taking anticoagulants.

But what happens to patients with a failed ablation? Dr. Callans asked, are their A-Fib symptoms worse? Are they at increased risk of stroke despite anticoagulation? Are they more likely to die (increased risk of mortality)?

In a 3-year follow-up study of non-paroxysmal A-Fib ablation at the Un. of Pennsylvania, the answers to these questions were not good. In the group that remained in persistent A-Fib (n=62), 20 had at least one repeat ablation. 96% remained on oral anticoagulants [I wonder: why weren’t 100% on anticoagulants?]. But A-Fib symptoms were generally manageable with rate control drugs. During the 3-year follow-up:

• Four had an AV Node Ablation and Pacemaker procedure (usually a measure of last resort; see my article, Ablation or Modification of the Atrioventricular (AV) Node and Implanting a Pacemaker)
• There were three deaths
• There were two strokes and one TIA (Transient Ischemic Attack, i.e., a temporary “mini-stroke”)
• There were two episodes of serious bleeding

Because of the small numbers, it’s hard to draw significant conclusions. But mortality was significantly higher in the group that remained in persistent A-Fib. This increased risk of mortality may be tied to increased comorbidities (i.e., obesity, diabetes, hypertension, sleep apnea, etc.) in this group.

Reference for this brief

Monitoring AF After Treatment: How Long and How?

Common practice today is to wait to assess the efficacy of catheter ablation for at least three months following catheter ablation—the “blanking period.”

But Dr. Suneet Mittal discussed the importance of monitoring AF burden (the amount of time the patient spends in A-Fib) during the blanking period. Dr. Mittal found that patients with more AF Burden during the blanking period were more likely to have recurrence. 100% of the patients studied with a >15% AF Burden during the blanking period experienced recurrence.

He also found that Intermittent Rhythm Monitoring (IRM) such as by 24-hour Holter monitors is significantly inferior to Continuous Monitoring (CM) by devices such as the Reveal LINQ Insertable monitor which a patient can have inserted under their skin for up to three years. Typical short-term monitoring (IRM) after an ablation may miss a great deal of A-Fib burden and chance of recurrence. But it may not be realistically possible to implant a CM device in all A-Fib patients.

Dr. Mittal recommended that current guidelines be changed to continue monitoring after an ablation. He added that after an ablation patients should be encouraged to take their pulse to monitor for irregularity and asymptomatic A-Fib episodes.

Reference for this brief

Report 2: Wrap Up Highlights

From the perspective of an A-Fib patient, the most exciting news was about developments to improve Contact Force sensing catheters. (They are already a huge improvement in RF catheter ablation). In addition to providing the EP with force and contact info, the new catheters will integrate duration, power, catheter stability and temperature to improve ablation quality.

The Laser Fiber Optic Balloon catheter seems also to have great potential. But we just don’t know if it will ever be approved for use in the U.S.

Dr. Callans pointed out that patients with a successful A-Fib ablation had very little stroke risk. Where as of those still taking anticoagulants after a successful ablation, 2% had an hemorrhagic stroke. Putting patients on anticoagulants after a successful catheter ablation is both ineffective and dangerous.

Dr. Mittal, and many at the Western Symposium presenters, expressed the increasing awareness that people over 65 need better monitoring than just an annual office ECG. The goal should be for everyone over 65 to have a practical form of continuous monitoring to detect A-Fib before it becomes a problem (i.e., causes a stroke). The challenge is finding a practical, cost-effective way to offer continuous monitoring to everyone over age 65. This is a major public health issue.

If you are on the NOACs Xarelto and Eliquis, Dr. Natale’s data is encouraging news. When having an ablation, you don’t have to switch back to warfarin beforehand. (They couldn’t say that about Pradaxa, see Pradaxa Danger Ablatlion—Switch to Warfarin.)

Also very encouraging, was Dr. Natale’s data that there were no strokes among the 2,618 ablations performed by his groups. This is especially impressive because among their patients, there was a higher prevalence of nonparoxysmal A-Fib and higher CHADS2 scores. (Translation: Their patients had more severe cases of A-Fib and more risk factors for stoke.) Could we be close to dropping ‘stroke’ as a possible complication during an ablation?

Look for my third report in the series in the coming weeks.

Doctors mentioned in this report along with their affiliations

Return to 2016 Western AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, April 14, 2016

2016 Western Atrial Fibrillation Symposium: Reports Written for Patients

2016 Western AF Symposium square logo BRIGHTER 2Park City, Utah! Snow. Snow! Snow!! What a wonderful winter venue for the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016.

After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant information was provided (sometimes by the same presenters).

Besides sharing technical research presentations, the Western AF Symposium also included ‘softer topics’ for doctors like using with social media and working with broadcasters to communicate with patients. In all, there were 53 scheduled presentations of 15 minutes each.

The first two reports are a condensed format with multiple topics per report. Email me and let me know if you enjoy this format.

Report  Topic  Publication date
3 Stroke: Is It A-Fib or Something Else?
Dr. Jennifer Majersik, The Stroke Center of the Un. of Utah  
 May 20, 2016
2 Summary Report 2 (covers 6 presentations)   April, 4, 2016
1 Summary Report 1 (covers 9 presentations)  March 21, 2016
More reports to come.

Report 1: Brief Summaries from the 2016 Western AF Symposium

Utah! What a wonderful winter venue for the Ninth Annual Western Atrial Fibrillation Symposium held  February 26-27, 2016.

Skiing in Park City, UT

Park City, UT

After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant information was provided (sometimes by the same presenters). In all, there were 53 scheduled presentations of 15 minutes each.

My first report includes 9 brief summaries of technical presentations.

Ablation vs Drugs: From AFFIRM to Recent Guidelines

Dr. Eric Prystowsky discussed the now somewhat notorious AFFIRM study which many cardiologist still use to justify keeping A-Fib patients on rate control drugs (and anticoagulants) while leaving them in A-Fib.

But the AFFIRM study was only for 3-5 years. Leaving someone in A-Fib for 20-30-40 years while only trying to keep their heart from beating too fast can have disastrous long-term consequences for A-Fib patients.

To continue reading, go to Report 1: 2016 Western AF Symposium.

My 1st Report from the 2016 Western AF Symposium

By Steve S. Ryan, PhD, March 2016

Utah! What a wonderful winter venue. The Park City Marriott was the site of the Ninth Annual Western Atrial Fibrillation Symposium held  February 26-27, 2016.

After having just attended the January 2016 AF Symposium in Orlando, FL, I was surprised at how much new, relevant info was provided (sometimes by the same presenters).

There were 53 scheduled presentations of 15 minutes each. A question & answer session followed every four presentations with the previous 4 speakers and moderators talking with the audience.

Skiing in Park City, UT

Park City, UT

In this first report, I’ve summarize 9 presentations and a Q & A session.

Ablation vs Drugs: From AFFIRM to Recent Guidelines

Dr. Eric Prystowsky discussed the now somewhat notorious AFFIRM study which many cardiologist still use to justify keeping A-Fib patients on rate control drugs (and anticoagulants) while leaving them in A-Fib.

But the AFFIRM study was only for 3-5 years. Leaving someone in A-Fib for 20-30-40 years while only trying to keep their heart from beating too fast can have disastrous long-term consequences for A-Fib patients.

Today’s guidelines recognize that it’s usually better for A-Fib patients to get back into normal sinus rhythm (NSR). But today’s antiarrhythmic drugs often don’t work. Once they fail, catheter ablation is superior. Today’s guidelines also recognize that it’s OK to do an ablation first, i.e., ablation can be a first choice. This means A-Fib patients don’t have to try and fail antiarrhythmic drugs before having an ablation.

Structural and Electrical Remodeling: From an Experimental Perspective

Hypercoagulability: a potentially dangerous condition in which blood coagulates excessively, even within the blood vessels.

Dr. Uli Schotten, gave perhaps the most innovative, breaking-new-ground presentation. He discussed how the very dangerous condition, hypercoagulability, is linked to fibrosis and A-Fib.

He discussed how NOACs (Novel Oral Anticoagulants) decrease the risk of an A-Fib stroke. In addition, they may also be a potential ‘Upstream Therapy’ to prevent the development of A-Fib by reducing hypercoagulability and the development of fibrosis.

[Think of ‘Upstream Therapy’ like living in a houseboat on a river. Anything upstream will ultimately affect you as it flows downstream. Furthermore, preventative steps ‘upstream’ can keep you from harm or improve your life ‘downstream’. See Upstream Therapy” Concept: Alternative Therapies for A-Fib?]

ASSERT Study: Are ‘Undetermined Source’ Strokes Actually from Silent A-Fib?

Dr. John P. DiMarco discussed stroke without any obvious causes (formerly called Cryptogenic, but now called “ESUS” [Embolic Stroke of Undetermined Source]). ESUS strokes accounts for 20%-30% of all strokes. He noted that, within two years of having an ESUS stroke, patients often develop A-Fib.

In addition, he discussed the ASSERT (Atrial Fibrillation Reduction Atrial Pacing Trial) study which studied 65-year-olds or older with hypertension. The study revealed that those with a pacemaker or ICD who experience a six minute or longer attack of ‘subclinical atrial fibrillation’ (asymptomatic or silent A-Fib), was at higher risk of stroke. Many ESUS strokes thought to be of “undetermined source”, may actually come from silent A-Fib.

Sleep Apnea and A-Fib

Dr. Larry Chinitz pointed out that sleep apnea, along with causing a host of other problems, expands the left atrium and causes fibrosis. CPAP (Continuous Positive Airway Pressure) breathing machines virtually eliminate sleep apnea and also reduce recurrence after an ablation.

The problem is 50% of patients don’t use theirs. These patients might be receptive to an alternative—a custom oral dental appliance that’s made by a qualified dentist in dental sleep medicine.

[These dental appliances prevent the airway from collapsing by supporting the jaw in a forward position. Caution: This may lead to misalignment of your jaw affecting your bite and causing headaches.]

In his practice, Dr. Chinitz requires that every A-Fib patient be screened for sleep apnea.

Proposed A-Fib Ablation Registry

During the question and answer session (following the above presentations), there was a lot of discussion about the proposed A-Fib ablation registry by the American College of Cardiology. The general consensus was: the ACC registry will be very burdensome and costly with 250 data points to be collected including a 20-question patient quality of life questionnaire; simpler, more focused, less burdensome registries are needed; they should be produced by electrophysiologists (EPs) instead.

You may recognize some of the speakers from my reports on the 2016 AF Symposium held in January.

How Many Times Can We Re-Do A-Fib Ablations?

Dr. Hugh Calkins stated that there is no limit to how many re-do ablation can be done. The risks for a second or third ablation compared to a first are similar. But there will be more RF scarring of the septum with each transseptal puncture. Dr. Calkins emphasized that re-do ablations should be done only after the blanking period (three months after the ablation). When re-doing an ablation, he always re-ablates (isolates) the PVs (Pulmonary Vein Openings).

Promoting AF Awareness Through The Media

Dr. John Campbell of Fox News explained how EPs should be media advocates. They should contact their local TV, radio and other media outlets and offer their services, particularly on Heart Health events or when news breaks about heart related topics.

He showed studies of how people can be greatly influenced by doctors on TV. In one study, for example, when doctors explained why to quit smoking, 1/3 of people hearing this advice did try to stop smoking. He also gave specific presentation advice and showed illustrative interview clips.

[See also my article: TV Doctors’ Talk Shows: Can You Trust Their Recommendations?]

Lesion Imaging Using MRI: Heating To Cooling

Utah is home to The CARMA Center at the U. of Utah, a leader in MRI research and A-Fib. 

Dr. Eugene Kholmovski showed how the unique and perhaps most important contribution MRI may make to A-Fib is to examine and accurately determine the integrity of A-Fib lesions. He showed many imaging slides and explained how a good lesion should look, and that it works for both lesions made with RF (heating) and Cryo (freezing) energy. When checking on the integrity of lesions, he cautioned to wait at least one week after ablation. Otherwise, edema (swelling caused by ablation) may prevent the MRI from clearly examining the lesion.

Gender Influence in Patients with Arrhythmia

Dr. Nazem Akoum reported he found few differences between male and female patients with A-Fib with two major exceptions. Women have more fibrosis than men, and women with fibrosis have a much higher risk of stroke.

How Social Media are Changing Managing Patients and Physician Approach

Dr. John Mandrola (‘Dr. John M’) gave several examples of how a researcher/EP can take advantage of social media channels like blogs, Twitter and Facebook to communicate with patients.

He gave the example of a researcher who writes a scholarly article “Warfarin vs the Novel Oral Anticoagulants.” This same article can be re-written for patients with a more patient-friendly title, such as, “How to Avoid a Stroke” and removing all the difficult-to-understand medical terms, then publish it as a blog post. In addition, the researcher can create a personal tweet: “I may have saved someone from having a stroke today. He started taking (name of anticoagulant).”

This shows how the same content can be re-written to reach patients through different media channels.

[Dr Mandrola is one of the more proficient EPs I know using social media and has a huge following. At DrJohnM.org, he blogs about A-Fib, heart rhythm and general cardiac matters, and the world of cycling.]

First Report: The Wrap Up

This is just my first report. There’s more coming in the following weeks.

I was surprised at how much new, relevant info was provided since the January international AF Symposium in Orlando. Besides technical research presentations, the Western AF Symposium also included ‘softer topics’ like using with social media and working with broadcasters to communicate with patients.

Return to 2016 Western AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, April 14, 2016

Doctors mentioned in this report with their affilications

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