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AF Symposium & other medical conferences articles

2021 AF Symposium: 5 New Summary Reports Posted

I’ve completed several new reports on presentations made at the 2021 AF Symposium. With each report, I strive to share the current state of the art in A-Fib research and treatments and what’s relevant to patients with Atrial Fibrillation. Symposium presenters are the best clinicians and researchers working in Atrial Fibrillation today. My new reports include:

Two Spotlight Sessions on New Technologies/Drugs: A new antiarrhythmic drug in development, and an inhaler that delivers Flecainide for fast results.

Two Clinical Trials: Results comparing the effectiveness of CryoBalloon ablation vs. Drug Therapy; and Findings from the ATTEST trial.

Research: The role of anticoagulants in A-Fib patients who develop cognitive impairment, cerebral microbleeds and dementia entitled “Cerebral Amyloid Angiopathy (CAA).

The new reports (with links):

Spotlight Session: New Technologies and Drugs―Flecainide Inhaler by InCarda Therapeutics
Spotlight Session: Drug in Development from Acesion Pharma
Anticoagulants and Cerebral Amyloid Angiopathy (CAA): Prevalence, Detection and Management
ATTEST Trial: Catheter Ablation to Modify Progression of AF
Another Study Finds Ablation Better First-Line Treatment Than Medication

Look for more of my reports from the 2021 AF Symposium in the next weeks and months. And, as always, my reports are written in plain language for A-Fib patients and their families.

Go to my list of all 2021 AF Symposium Reports

2021 AF Symposium: New Technologies and Drugs―Flecainide Inhaler by InCarda

2021 AF Symposium

New Technologies and Drugs―Flecainide Inhaler by InCarda Therapeutics

Jeremy Ruskin, MD, Mass. General Hospital and AF Symposium

Jeremy Ruskin, MD

Dr. Jeremy Ruskin of Massachusetts General Hospital gave a 5-minute Spotlight Session talk on InCarda Therapeutics’ flecainide inhaler. InCarda is a privately held biopharmaceutical company in Newark, CA.

Dr. Ruskin described the InCarda inhaler which uses flecainide, a well-established antiarrhythmic agent.

Flecainide Inhaler from Carda Therapeutics

When a patient with recent onset A-Fib self-administers the breath-activated inhaler, it produces a flecainide-containing aerosol when the patient inhales. This results in a rapid absorption of flecainide via the lungs into the heart. An A-Fib attack can be terminated in as little as 8 minutes.

By contrast, if flecainide is taken as a pill-in-the-pocket, it often takes much longer for the pill to work (20-30 minutes).

Aside from the problems associated with flecainide, this inhaler is generally safe and well tolerated.

“Cmax ” is a pharmacology term meaning the peak serum concentration of a therapeutic drug. 
It’s “Cmax dependent” which means its peak plasma concentration is a function of dose and speed of administration, but primarily determined by dose.

According to Dr. Ruskin, “Inhaled Flecainide has the potential to be a practical, cost effective option for rapid conversion of AF to sinus rhythm.”

Editor’s Comments

The InCarda flecainide inhaler is already in FDA Phase II trials. But it will probably still be a couple of years before it’s generally available to doctors and patients.
InCarda Inhaler Better Than Pill-In-The-Pocket: The InCarda flecainide inhaler is or will be a welcome addition to Pill-In-The-Pocket therapy where patients only take a drug when it’s needed, not all the time. Today’s antiarrhythmic drugs can have bad side effects and be poorly tolerated if taken all the time. Think of how  liberating it would be to just use an inhaler to quickly get out of an A-Fib attack.

One wonders if the InCarda inhaler can be developed for anticoagulants as well. Anticoagulants are high risk drugs especially for older patients. 

f you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021

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2021 AF Symposium: ATTEST Trial—Catheter Ablation to Modify Progression of AF

2021 AF Symposium

ATTEST Trial: Catheter Ablation to Modify Progression of AF

Dr. Karl-Heinz Kuck

Dr. Karl-Heinz Kuck of the Asklepios Klinik St. Georg in Hamburg, Germany, gave a presentation on the findings from the ATTEST Trial. (He also spoke on this topic at the 2020 AF Symposium).

Patient Risk: Progressing from Paroxysmal to Persistent A-Fib

Dr. Kuck pointed out that within one year, 4% to 15% of paroxysmal A-Fib patients become persistent.

In addition: they are at a higher risk of dying, they have more risk of stroke, and it’s more difficult to restore them to normal sinus rhythm. (In the Rocket AF trial, the mortality rate of persistent A-Fib was triple that of paroxysmal patients.)

The ATTEST Trial: RF Ablation vs Antiarrhythmic Drugs

The ATTEST clinical trial included 255 paroxysmal patients in 36 different study locations. They were older than 60 years and had to have been in A-Fib for at least 2 years (mean age 68). They had failed up to 2 antiarrhythmic drugs (either rate or rhythm control).

Patients were randomized to two groups: radiofrequency ablation (RF) (128) or antiarrhythmic drugs (127). They were followed for 3 years (ending in 2018).

ATTEST Findings

Significant data about the progression of A-Fib was learned from this trial.

• At 3 years, the rate of persistent A-Fib or atrial tachycardia was lower (2.4% ) in the RF group vs the antiarrhythmic drug group (17.5%).

• The RF group was approximately 10 times less likely to develop persistent A-Fib compared to the antiarrhythmic drug group.

• For patients in the antiarrhythmic drug group, 20.6% progressed to persistent A-Fib or atrial tachycardia compared to only 2.2% in the RF group.

• Recurrences occurred in 49% of the ablation group vs. 84% in the drug group. Repeat ablations were done on 17.1% of the ablation group.

Dr. Kuck’s advice: “Ablate as early as possible.”

Dr. Kuck’s Conclusions

Early radiofrequency ablation was superior to antiarrhythmic drugs to delay the progression to persistent atrial fibrillation among patients with paroxysmal A-Fib.

Dr. Kuck’s advice: “Ablate as early as possible.”

Editor’s Comments

The EAST-AFNET 4 Trial: The ATTEST Trial findings dovetailed with results from the EAST-AFNET 4 Trial.

Dr Paulus Kirchhof

In another ’21 AF Symposium presentation, Dr. Paulus Kirchoff (Institute of Cardiovascular Sciences, U. of Birmingham, UK) reported that EAST-AFNET 4 trial findings supported early initiation of rhythm therapy in cases of recent onset A-Fib. (See 2021 AF Symposium: EAST-AFNET 4 Trial—Early Rhythm Control Therapy in AF)
Research by both Dr. Kuck and Dr. Kirchhof came to the same conclusion: “ablate as early as possible” and the need for “early initiation of rhythm therapy.”
Why Risk Progressing into Persistent A-Fib? There are so many bad things that can happen to you when left in A-Fib. As Dr. Kuck points out, you’re at a higher risk of dying, there’s more risk of stroke, it’s more difficult to restore you to normal sinus rhythm.
And we haven’t even talked about heart damage from fibrosis, the risk of electrical remodeling of the heart, and the all-too-real dangers of taking antiarrhythmic drugs over time.
And what about quality of life? Who wants to live in A-Fib? There are few medical procedures so transformative and life changing as going from A-Fib to normal sinus rhythm.
Don’t Leave Someone in A-Fib―Ablate as Early as Possible: Dr. Kuck’s (and Dr. Kirchhof’s)  research answers once and for all whether or not A-Fib patients should be left in A-Fib, whether seriously symptomatic or not (e.g., leaving A-Fib patients on rate control drugs but still in A-Fib.)
These patients are 10 times more likely to progress to persistent A-Fib. That’s why today’s Management of A-Fib Treatment Guidelines lists catheter ablation as a first-line choice. That is, A-Fib patients have the option of going directly to a catheter ablation.
Research supports the same conclusion: “ablate as early as possible” and the need for “early initiation of rhythm therapy.”
Time for a Second Opinion? I occasionally hear of Cardiologists who refuse to refer patients for a catheter ablation, who tell patients a catheter ablation is unproven and dangerous. Not true!
When you hear something like that, it’s time to get a second opinion and/or change doctors.
Know Your Rights—Be Assertive: Your doctor may try to talk you into first trying antiarrhythmic meds before offering you the option of a catheter ablation.

As an A-Fib patient, know your rights and be assertive. According to the Management of Atrial Fibrillation Treatment guidelines, you have a right to choose catheter ablation as your first choice.

If you find any errors on this page, email us. Y Last updated: Friday, April 16, 2021

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2021 AF Symposium: Another Study Finds Ablation Better First-Line Treatment Than Medication

2021 AF Symposium

Another Study Finds Ablation Better First-Line Treatment Than Medication

To date there have been many research studies demonstrating the superiority of ablation versus drug therapy for A-Fib.

Dr. Jason Andrade

This is a Canadian study of CyroBalloon ablation by lead author Dr. Jason Andrade of University of British Columbia Faculty of Medicine. According to study researchers, CryoBalloon ablation “is a more effective first-line treatment for (A-Fib) patients than medication.”

It was better at preventing symptoms of A-Fib from recurring at all, and reduced the amount of time some patients experienced A-Fib.

The Study: CryoBalloon Ablation Halved Rate of Recurrence vs. Drugs

All 303 patients were treated for A-Fib for the first time in their lives. Half were randomized to receive CryoBalloon ablation, while the other half were treated with antiarrhythmic drugs (AADs).

Of the Cryo-Balloon group, 57.1% didn’t have a recurrence of some form of an irregular heartbeat by the one-year mark [not as high a success rate compared to other studies]. While the success rate of the AAD group was only 32.2%.

CryoBalloon ablation halved the rate of recurrence compared to usual drug therapy.

Additional Benefit: CryoBalloon Ablation Improved Quality-Of-Life

Ablation outperformed the drug group in terms of quality-of-life improvement. Eighty-nine per cent of CryoBalloon patients were free of symptomatic arrhythmia episodes.

According to Dr. Andrade, “Patients who received cryoballoon ablation were more likely to be symptom-free and not require hospitalization for their atrial fibrillation.”

Editor’s Comments

Choose Ablation Over Drugs: Dr. Andrade states explicitly that A-Fib patients should think of catheter ablation as first-line therapy, not something you do after trying multiple antiarrhythmic drugs (AADs).
This is in accordance with current best practices i.e., Guidelines for the Management of Patients with Atrial Fibrillation. AADs don’t work half as well as catheter ablation. In the real world, AADs are ineffective, cause bad side effect, or lose what effectiveness they had over time. And while you’re wasting a year or two trying various AADs, you’re usually still miserable in A-Fib.
Catheter Ablation Transforms Your Life: An A-Fib attack can totally incapacitate you. Even mild to moderate A-Fib can make you feel unwell, produces shortness of breath, brain fog, etc. You may be unable or reluctant to pursue normal activities like traveling and exercise. And you often live in fear of the next A-Fib attack. Or you’re angry and frustrated at your out-of-control heart.
A catheter ablation can change all that.

There are few medical procedures so transformative and life changing as a successful catheter ablation. Ask any former A-Fib patient who is now A-Fib free.

Resources for this article

• A procedure, not medication, may be a more effective first-line of treatment for common heart rhythm problem. UBC Faculty of Medicine, November 24, 2020. https://www.med.ubc.ca/news/a-procedure-not-medication-may-be-a-more-effective-first-line-of-treatment-for-common-heart-rhythm-problem/

• Minimally invasive procedure beats meds for atrial fibrillation. Bottom Line Personal, Volume 42, Number 8, April 15, 2021.

f you find any errors on this page, email us. Y Last updated: Friday, April 16, 2021

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2021 AF Symposium Spotlight Session: Drug in Development from Acesion Pharma

2021 AF Symposium

Spotlight Session: Drug in Development from Acesion Pharma

At this year’s AF Symposium, there were 22 Spotlight Session talks 5 minutes long spread out over 3 days. Normally I don’t report on them in detail, since they usually aren’t currently available (and may never make it through development and regulatory hurdles into the marketplace). But here’d one that may be of interest to patients.
Dr. John Camm - A-Fib.com

Dr. John Camm

Dr. John Camm of St. George’s Hospital in Oxford, UK discussed a drug in development from Acesion Pharma, a Danish biotech company.

This new drug (AP30663) is highly atrial specific and works as an SK channel inhibitor [to suppress A-Fib]. SK channel inhibitors are ion channels present in the heart which regulate the cardiac rhythm.

Acesion’s new drug is designed for IV cardioversion of A-Fib to normal sinus rhythm.

Editor’s Comments:

Just the fact that Acesion is working on a new antiarrhythmic drug is news in itself. It’s been years since any new antiarrhythmic drugs have come on the market. And the antiarrhythmic drugs currently available to patients leave a lot to be desired.

Plus, the Acesion drug being developed is highly atrial specific which is an important advantage over most other antiarrhythmics.

If you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021

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’21 AF Symposium Report: Pulsed Field Ablation for Atrial Fibrillation with Lattice-Tip Catheter

I’ve posted a new report about an ablation for a patient with persistent A-Fib who had been cardioverted and was now in Atrial Flutter. Drs. Reddy and Neuzil demonstrated a new, innovate strategy of using Pulsed Field Ablation (PFA) combined with RF ablation developed by AFFERA, Inc.

The AFFERA lattice catheter

The AFFERA lattice catheter

Symposium attendees watched the ablation live via streaming video from the Czech Republic.

The AFFERA system uses a single lattice-tip catheter but two different energy generators, one for PFA and another for RF ablations.

One of the great advantages of Pulsed Field Ablation (PFA) is that the PF energy doesn’t damage adjacent tissue or structures such as the Phrenic nerve or the esophagus. So the doctor can switch back and forth between energy sources depending on the lesion location and surrounding tissue/organs.

When the AF Symposium audience joined the live video feed, the doctors and their team had started the procedure. The Pulmonary Veins (PVs) were already isolated and they had created a Flutter map. To continue reading…go to “Pulsed Field Ablation for Atrial Fibrillation Using a Lattice-Tip Focal Catheter”.

2021 AF Symposium Live Case: Pulsed Field Ablation for Atrial Fibrillation Using a Lattice-Tip Focal Catheter

2021 AF Symposium

Live Case: Pulsed Field Ablation for Atrial Fibrillation Using a Lattice-Tip Focal Catheter

2021 AF Symposium Live Streaming Video

In a live ablation case titled “Pulsed Field Ablation for Atrial Fibrillation Using a Lattice-Tip Focal Catheter”, Drs. Vivek Reddy and Petr Neuzil demonstrated a new, innovate strategy of using Pulsed Field Ablation (PFA) combined with RF ablation developed by the private company AFFERA, Inc. (Watertown, MA).

Dr. Vivek Reddy is with Mount Sinai Medical Center in New York City and Dr. Petr Neuzil is with Homolka Hospital, Prague, Czech Republic.

The AFFERA System

The AFFERA system

The AFFERA system uses a single lattice-tip catheter but two different energy generators, one for PFA and another for RF ablations.

One of the great advantages of Pulsed Field Ablation (PFA) is that the PF energy doesn’t damage adjacent tissue or structures such as the Phrenic nerve or the esophagus.

A simple foot pedal is used to switch between the two energy generators. A PF ablation appeared as a green dot on the mapping screen. An RF ablation appears as a red dot.

[For more about PFA, see 2020 AF Symposium: Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.]

Live Via Streaming Video

The Patient’s History: Dr. Reddy’ patient had been in persistent A-Fib, was cardioverted, but went into typical Flutter.

Live from Prague, Czech Republic: When the Symposium audience joined the live video feed from Prague, the doctors and their team had already started the procedure.

The Pulmonary Veins (PVs) were already isolated. They had created a Flutter map.

Posterior Wall Ablation Using PFA: The Symposium audience watched as Dr. Reddy used the system to make PF ablations in areas of the heart. Although near other structures the PF ablation energy only affected the heart tissue, not any of the nearby tissue or organs located just behind the heart.

Dr. Reddy had started working on ablating the posterior wall using 4-second PFA lesions. A bullseye symbol would first appear on the monitoring screen where the lesion was aimed. We were amazed at how fast Dr. Reddy could make a roof line on the posterior wall using PFA.

Dr. Reddy pointed out that there was no significant temperature change when applying PFA lesions. When asked about using a temperature probe in the esophagus, he explained that at first, they did use a temperature probe. After 70-80 cases, they didn’t see any significant temperature changes. Today they no longer use temperature probes in the esophagus.

PFA Faster Than RF Ablations

When switching to PFA, Dr. Reddy only had to apply PFA for 3-5 seconds which is much faster than typical point-by-point RF ablation. The entire lattice-tip delivered a series of micro-second PFA pulses. Saline irrigation was still used as in RF delivery [but one wonders why this is necessary]. There was no need for temperature feedback when using PFA.

In one instance, when a mitral line block was not achieved with the lattice tip, Dr. Reddy switched to RF to make a coronary sinus (CS) ablation. (Although, in most situations, PFA worked well to isolate the CS without having to use RF.)

Spacing Between Ablation Dots

Red dots are RF ablations; Green dots are PFA.

He explained that they are now using a 4 mm spacing PFA distance between ablation spots, but this may change with more experience and data. Spacing of 6 mm may be enough for isolation.

As Dr. Reddy moved away from near the esophagus, he double clicked on the pedal to switch to RF to make ablations in areas of the heart not adjacent to areas that could be damaged by RF energy, such as isolating/ablating around some of the Pulmonary Veins (PVs). When using RF, he increased his spacing between lesions to 6-7 mm. “With RF we think we get a much wider lesion.”

He showed how the AFFERA software showed a gap in blue which indicated too wide spacing. He had preset the software to show blue with any gap larger than 8 mm.

After finishing the mitral isthmus roof line, the Symposium moderator switched away from Dr. Reddy to another live streaming video presentation.

Why Use Both PFA and RF?

Dr. David Keane from St. Vincent’s hospital in Dublin, Ireland asked the question we all wanted to know. “Why? Why even bother with RF in these cases?” If PFA works so well, why use RF at all?

The Lattice catheter

Dr. Reddy stated, “I’m not saying we will never go to pure PFA.” But he also acknowledged that 60 to 70 percent of his ablations using the AFFERA system were made with PFA. In this study itself, they ablated 60-70 patients using only pure PFA.

Dr. Reddy indicated that being able to use RF at times during an ablation may give operators more flexibility to go after more elusive signals such as Atypical Flutter. “This approach may wind up being preferred in many patients. We will see.”

Technical Achievement: The Lattice-Tip Catheter

The Lattice-tip catheter is probably worth a report on its own. It looks like a sphere which can be changed and compressed to different shapes. It’s mounted on a deflectable catheter with an expandable 9-mm diameter nitinol lattice electrode which contains 9 mini-electrodes on the spherical surface.

It also has embedded thermocouples for temperature control and an irrigation pump for saline during RF ablation along with an integrated mapping system.

During this live procedure, Dr. Reddy demonstrated how the Lattice-tip catheter can be changed to shapes like a football or to function like a point-by-point RF catheter.

It can make lesions very rapidly because of its wide footprint and improved catheter stability. It can make wide ablation lines. And the compressibility of the lattice mesh and its spring-like interaction with tissue, make for better and wider lesions.

Being able to both map and create lesions using the same catheter is a technical achievement that will make EPs job much easier and more efficient.

Editor's Comments about Cecelia's A-Fib storyEditor’s Comments

Some have said that, since almost all EPs are experienced in using RF, a combination system using both RF and PFA might be more easily used by EPs. EPs know from experience how well RF works and the durability of RF lesions. But to me the AFFERA system is at best a transitional treatment and can’t compare to pure PFA.
What was confusing, at least for me, was that at last year’s AF Symposium Dr. Reddy presented ground-breaking research on Pulsed Field Ablation using the Farapulse system. I only found out later that Dr. Reddy’s presentation this year about the AFFERA system was actually in competition with Farapulse.
Despite the technological innovation of the AFFERA, Inc. PFA and RF combination system, it’s unlikely that it will be adapted by the EP community in the long run. “Pure” PFA seems to work so well that there doesn’t seem to be a need for a combination system. But I could be proven wrong. Maybe there are difficult signal areas that PFA may not be able to adequately address with the same effectiveness as RF ablations.

The LIRYC Bordeaux group is starting a 5-year study to compare RF ablations  with PFA which should answer most of these questions. (Also see ’21 Symp: Pulsed Field Ablation Using Multielectrode Catheters and PFA Compared to RF Study)

Resource for this article

• Reddy, V.Y. et al. Lattice-Tip Focal Ablation Catheter That Toggles Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. Circulation: Arrhythmia and Electrophysiology, Vol. 13, No. 6. https://www.ahajournals.org/doi/10.1161/CIRCEP.120.008718

• Atrial Esophageal Fistula: The esophagus often lies right behind the left atrium posterior wall or behind a particular Pulmonary Vein. RF heat applied to nearby tissue can damage the esophagus often with deadly complications.

AF Symposium ’21—New Report with Dr. Pierre Jais on Pulsed Electrical Field Ablation for Atrial Fibrillation

Pierre Jaïs, MD

My next report from the 2021 AF Symposium is on the short side.

Dr. Pierre Jais of the French Bordeaux Group (LIRYC) covers two topics; first, he briefly discusses pre-clinically testing of Pulsed Electrical Field ablation (PEF), Then he briefly covers the BEAT AF 5-year study which compares the effectiveness of PEF to standard RF ablation. Read it now, go to my report.

2021 AF Symposium Reports: More to Come

You’ll find my growing list of reports on the 2021 AF Symposium page. (You’ll find the link of the left menu of the website,)

As always, I write these summary reports to offer A-Fib.com readers the most up-to-date research and developments that may impact their treatment choices. All my reports are written in plain language for A-Fib patients and their families.

2021 AF Symposium: Pulsed Field Ablation Using Multielectrode Catheters and PFA Compared to RF Study

2021 AF Symposium

Pulsed Field Ablation Using Multielectrode Catheters and PFA Compared to RF Study

Note: At last year’s AF Symposium, the term “Pulsed Field Ablation” (PFA) was used. This year Dr. Jais used the phrase “Pulsed Electrical Field ablation” (PEF).

Pierre Jaïs, MD, The Bordeaux Group

Presenter: Dr. Pierre Jais of the French Bordeaux Group (LIRYC) 

Topic 1: “Pulsed Electric Field Ablation and the Multielectrode Basket/Flower Array for Paroxysmal and Persistent AF”.

Farapulse catheter: Five Petal Flower Configuration

Farapulse catheter: Five Petal Flower Configuration

Background: Dr. Pierre Jais first explained how Farapulse, Inc. developed Pulsed Electric Field Ablation (PEF) by pre-clinically testing it on 700 swine to improve the device, delivery design, the generator, the catheters, to demonstrate safety, and the absence of unwanted lesions.

Testing on 121 paroxysmal patients: Next, he discussed recent human testing on 121 patients with paroxysmal Atrial Fibrillation at 3 different European centers . With 5 different operators, procedure times were about 1 hour with 35 minutes of LA dwell time. They used 20 minutes of mapping which is not required in routine practice.

Results: They had 4 (non-serious) adverse  events with no phrenic nerve damage, PV stenosis, stroke, or infarction. At 3 months they had a 96% success rate of durable PVI.

The PEF catheter does not require actual physical contact but only needs proximity to the tissue to be ablated. And it doesn’t cause scarring or char formation.

What is Pulsed Electric Field Ablation? PEF is a non-thermal energy system that uses a series of ultra-short electrical pulses to ablate heart tissue in seconds. More importantly, PEF works on the selected cell types while leaving others alone (like the esophagus).

Topic 2: The BEAT AF Study: PEF Compared to RF

According to Dr. Jais, one of the most important questions facing researchers: Is Pulsed Electrical Field ablation (PEF) indeed better than standard RF ablation?”

Farapulse open basket catheter configuration

From all the previous preliminary research on PEF, one would assume PEF is better than standard RF ablation. [See 2020 AF Symposium: Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation] But answering a question this important can’t be assumed.

Dr Jais discussed the BEAT AF randomized five-year study. It will attempt to demonstrate that isolation of the Pulmonary Veins (PVs) by Pulsed Electrical Field ablation is more effective, faster, and safer than Radiofrequency (RF) ablation (the current standard or reference ablation treatment). It will involve 10  European centers.

Editor’s Comments:
BEAT AF Randomized Five-year Study: Normally I don’t discuss studies until the results have come out. But PEF is different. Pulsed Electrical Field ablation is a new technology that offers a real hope of a revolutionary, break-through strategy to cure A-Fib.
Even though PEF is not yet FDA approved, its potential is incredible and a real game changer both for doctors and patients.

If you find any errors on this page, email us. Y Last updated: Friday, March 12, 2021

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2021 AF Symposium: Cerebral Amyloid Angiopathy & Anticoagulants—Prevalence, Detection and Management

2021 AF Symposium

Cerebral Amyloid Angiopathy (CAA) and Anticoagulants: Prevalence, Detection and Management

Dr. M. Edip Gurol

Background: For A-Fib patients, Dr. Mahmut Edip is a very important researcher. Many doctors consider anticoagulants as little more than a type of benign vitamin. Dr. Gurol’s studies and observations show how anticoagulants, particularly in older patients, can be dangerous drugs and contribute to brain bleeds.

Dr. Mahmut Edip Gurol from Massachusetts General Hospital in Boston, MA, gave a presentation about the role of anticoagulants entitled “Cerebral Amyloid Angiopathy (CAA): Prevalence, Detection and Management.

Anticoagulants Increase the Risk of Hemorrhagic Stroke!

In previous presentations, Dr. Gurol has shown that anticoagulants may actually increase the risk of Intracerebral Hemorrhage (ICH) stroke. Dr. Gurol’s images of cerebral microbleeds (CMBs) and the fatal strokes they can cause are a real wake-up call, especially to most older A-Fib patients. For more, see my article featuring Dr.Gurol: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes

LEFT: Brain MRIs of two microbleeds in the same older adult with A-Fib taking a NOAC (red arrows point to tiny microbleed dots). RIGHT: Two years later, the patient had a hemorrhagic stroke and died. The right MRI shows the fatal hemorrhage.

“Angiopathy” means a disease of the blood vessels, especially where small blood vessels are damaged and burst open.
“Amyloid” is an abnormal protein produced in bone marrow that  can be deposited in any tissue or organ.

Cerebral Amyloid Angiopathy (CAA)

In his presentation at the 2021 AF Symposium, Dr. Gurol discussed Cerebral Amyloid Angiopathy (CAA) which is an accumulation of pathological amyloid beta proteins in superficial brain vessels.

Cerebral Amyloid Angiopathy (CAA) is a common cause of bleeding into brain tissue in older adults and is associated with a high risk of hemorrhagic recurrence. It contributes to age-related cognitive decline and is considered largely untreatable. CAA often accompanies Alzheimer’s disease.

CAA can be viewed in some ways as a canary in a coal mine [early warning signal] that may set in motion a damaging disease process.

Anticoagulants Can Affect CAA Causing Brain Bleeds and Increased Risk of Mortality

Dr. Gurol said that cognitive impairment and dementia are very prevalent in CAA patients. They are likely the result of brain injuries including cerebral microbleeds.

He referenced MRI studies that show that CAA can develop into Intracranial Hemorrhages (ICH) due to oral anticoagulant use.

In addition, Dr. Gurol discussed the increased mortality risk for patients on anticoagulants. As examples, he cited the mortality risk associated with the following:

▪ Warfarin 25% increased risk
▪ Rivaroxaban 14% increased risk
▪ Apixaban 5.4% increased risk

To avoid this increased risk of mortality, he recommended nonpharmaceutical approaches such as removal of or closing off the LAA for patients with CAA.

Dr. Gurol stressed the need for increased cooperation between stroke neurologists and EPs.

Editor’s Comments

Anticoagulants are High-Risk Drugs: Some pharmacists and doctors have always described anticoagulants as high-risk medications (Drs. Witt and Hansen).
Listening to Dr. Gurol makes the risk real, understandable, and relevant. You can’t argue when Dr. Gurol shows slides of microbleeds, describes how almost everyone over age 65 has them, then shows a photo of how deadly a hemorrhagic (brain bleed) stroke can be.
In MRI studies, 97% of patients taking NOACs had ICH markers. It’s all too easy for NOACs to expand these microbleeds into full blown Intracerebral Hemorrhages.
Should Patients Over Age 65 Be Taking Long-Term NOACs? Dr. Gurol and his colleagues did not say that people over 65 taking NOACs long-term will eventually develop Hemorrhagic strokes. But the chances of developing a Hemorrhagic stroke are alarmingly high. No one over age 65 should be taking long-term NOACs, unless there is no other option. The risk is simply too high. .

What Else Can You Do? …Remove the reason for an anticoagulant! Read about the three options to taking anticoagulants in my article: A-Fib Drug Therapy: Anticoagulant Side Effects and Alternatives.

Resources for this article

• Witt, Daniel W. and Hansen, Alisyn L. editorial in New Oral Anticoagulants Can Require Careful Dosing Too. by Scott Baltic. Medscape/Reuters Health Information, December 29, 2016. http://www.medscape.com/viewarticle/873821?src=wnl_edit_tpal

• Charidimou, A. et al. Emerging concepts in sporadic cerebral amyloid angiopathy. Brain, 2017 Jul; 1829-1850. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6059159/ doi: 10.1093/brain/awx047

If you find any errors on this page, email us. Y Last updated: Tuesday, April 20, 2021

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