2013 BOSTON ATRIAL FIBRILLATION SYMPOSIUM

Live Satellite and Prerecorded Case Presentations

by Steve S. Ryan, PhD

The live Satellite Case Presentation was from Massachusetts General Hospital by Dr. Moussa Mansour and his colleagues Dr. Kevin Heist and Dr. Conor Barrett. We watched live as they inserted a Lariat II noose-like Left Atrial Appendage (LAA) closure device in an 84-year-old man with A-Fib. He would get nose bleeds with frequent emergency room visits when he took Coumadin. He also had pulmonary fibrosis and had been on many different meds. His CHADS2 score was 2, his CHADS-VAS2 was 4 which indicated he ought to be on anticoagulants to prevent an A-Fib stroke. But his HASBLED score was 4 which meant he was at risk of having a hemorrhagic stroke if he takes anticoagulants. By closing off the LAA where 95% of A-Fib clots come from, he would be protected from an A-Fib stroke and wouldn’t have to take anticoagulants.

Dr. Mansour inserted a catheter with a balloon through the man’s groin and into his left atrium, then into his Left Atrial Appendage (LAA). He used the balloon to pump up the LAA so that the Lariat II noose could be placed over it from the outside of the heart. Then he inserted a second catheter with a magnet from outside the man’s chest. He went through the pericardial sack surrounding the heart and advanced it to the LAA. He then inserted a third catheter with a magnet into the inside of his heart to the base of the LAA which he attached to the other magnet around the LAA. He used this link to pull in the Lariat II noose which he slipped over the LAA. Once he had secured the noose, he removed the balloon from inside the LAA. Then he tightened the noose and tied it off. We could see a crease inside the heart where the LAA opening once was.

Later in the afternoon Dr. Mansour also did a live ablation using the Electromagnetic Navigation System with X-Ray Integration. This is basically ablation without X-Ray. He wound up using less than five minutes of fluoroscopy to navigate within the heart.

In addition to the live cases, several doctors also presented pre-recorded presentations.
Dr. Young-Hoon Kim from Korea University Medical Center showed a very difficult case of a 27-year-old who was returning for an additional ablation. It was fascinating to watch an EP “detective” at work. Using a variety of mapping techniques, Dr. Kim was able to track down and ablate A-Fib producing spots throughout the left and right atria. Some of these spots were in very unusual locations such as the Right Atrial Appendage, high septum and Bachman’s Bundle. The appendage was electrically isolated, but was still contracting properly. Dr. Kim’s facility in Seoul does over 1000 ablations a year with 50% being for A-Fib.

Dr. Vivek Reddy of Mount Sinai Medical Center in New York presented the most innovate and cutting edge use of catheter ablation—“renal denervation.” Recent research has found that when one ablates some of the nerves going to the kidneys, this dramatically lowers blood pressure in people who can’t otherwise lower their high blood pressure. It also seems to diminish A-Fib attacks. (This makes intuitive sense, since hypertension is a known trigger or cause of A-Fib.) It was fascinating to watch Dr. Reddy thread his catheter up an artery and branch off to the arteries supplying the kidneys. He seemed to burn only once or twice in each branch to disrupt some of the nerve pathways to the kidneys. These burns didn’t seem to affect the integrity of the arteries. (The author had never seen anything like this before.)

Dr. Francis Marchlinski of the University of Pennsylvania in Philadelphia showed an ablation using Jet Ventilation. Jet Ventilation doesn’t stop the heart from beating as in bypass surgery. But to this observer it seemed to put the heart in a type of slow motion with a lot less movement than when the heart is beating in normal sinus rhythm. Slowing down the heart like this helps the ablation doctor make lesions in hard-to-access areas. (The inside of the heart is not a uniformly smooth surface and can have wide anatomical differences depending on the person. For example, the author has five Pulmonary Veins rather than the usual four. Two of my PVs are very close together without a lot of room for an ablation catheter. The heart has varying degrees of thickness and ridge areas where it’s hard to make lesions. By slowing down the natural movement of the heart, Jet Ventilation allows the ablation doctor to, for example, better hold the catheter tip on a ridge area.) Dr. Marchlinski said that, once his colleagues try Jet Ventilation, they become enthusiastic users.

Dr. Andrea Natale of the Texas Arrhythmia Institute in Austin showed an ablation of a 74-year old with persistent A-Fib and significant scarring. (This is usually the most difficult case ablation doctors encounter.) To finally terminate the A-Fib, Dr. Natale had to ablate around and electrically isolate the Left Atrial Appendage (LAA).He stressed that ablating the LAA is often the key to a successful ablation, that doctors should look to the LAA when they are trying to find elusive sources of A-Fib.

Dr. Douglas Packer of the Mayo Clinic in Rochester, Minnesota showed a CryoBalloon ablation using the new CryoBalloon catheter. This balloon catheter has eight jets instead of four which means more area of the balloon can produce freezing. The old balloon produced freezing only near the equator of the balloon. The newer balloon can produce freezing more easily in the smaller Pulmonary Veins.

Dr. David Wilber of Loyola University Medical Center in Chicago did an ablation that demonstrated how to use low voltage electrograms to find and ablate high frequency potentials which produce A-Fib signals. The patient he was ablating had failed both ablations and a Thorascopic Maze operation. Because of the previous scarring, he wasn’t able to pace the patient. After extensive mapping, he found and ablated all the errant A-Fib sources including a leak in a previously made roof line.

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Last updated: Friday, February 13, 2015

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