Doctors & patients are saying about 'A-Fib.com'...


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Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"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

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


AF Symposium & other medical conferences articles

2020 AF Symposium Abstract: Using MRI to Check Pulsed Field Ablations (PFA)

2020 AF Symposium Abstract

Using MRI to Check Pulsed Field Ablations (PFA)

by Steve S. Ryan

Background: Pulsed Field Ablation (PFA) is a new treatment for Atrial Fibrillation with some unique features. First, the ablations are tissue-specific, only affecting heart tissue and not the surrounding organs. Second, instead of direct contact to make lesions, as with RF ablation, all that’s necessary is proximity to the targeted tissue to make the ablation.

Pierre Jaïs, MD, The Bordeaux Group

In a remarkable statement that would strike terror in the heart of most Electrophysiologists (EPs), the French Bordeaux group stated about Pulsed Field Ablations:

Measures to alter lesion placement based on proximity of the esophagus and phrenic nerve were not taken.”

Normally, during a RF or cryo ablation, doctors move the esophagus as far away as possible from where they are ablating. In this study they took no such precautions.

Pulsed Field Ablation (PFA) study

Farapulse catheter – Five Petal Flower configuration

At this year’s AF Symposium, the French Bordeaux group presented an abstract of their study using Pulsed Field Ablation (PFA) with MRI.

Study Technique: With the Pulsed Field Ablation (PFA) waveform generator, they used a 5-spline 12F catheter to isolate the Pulmonary Veins (PVs). Then, they used MRI to check the PFA lesions to assess any extra-cardiac damage.

Study Results

NO DAMAGE TO THE ESOPHAGUS

Position of Esophagus behind the heart

In 17 patients, the esophagus was located directly behind and adjacent to PFA lesions at a distance of 0.5 to 2 mm. Post PFA ablation and using MRI imaging, they found no esophageal lesions.

They also found no discontinuities (gaps) in any isolated PV.

(With other energy ablation sources such as RF, the esophagus would be scarred, have ulcer-like damage, and fistula.)

NO PHRENIC NERVE DAMAGE

Phrenic nerve near heart

When they ablated the right PVs, they knew that they were right next to or close to the phrenic nerve.

Upon examination, PFA lesions were found in the area of the phrenic nerve but no damage was seen (despite the fact that there was consistent phrenic nerve capture during PFA delivery).

LESS THAN 60 SECONDS PER PATIENT

And even more remarkably, the total energy delivery time per patient was less than 60 seconds. This is much less time than with other types of ablation.

Editor’s Comments:
I expect Pulsed Field Ablation (PFA) will revolutionize catheter ablation for A-Fib. This is incredibly good news for patients and will make the EP’s job much easier requiring less time in the EP lab.

Better for Patients

Atrial-Esophageal Fistula No Longer a Threat: These are remarkable results! When using Pulsed Field Ablation (PFA), EPs don’t have to worry about damaging the esophagus, even though the PFA catheter may be very close to the esophagus. The dreaded complication Atrial-Esophageal Fistula will become a thing of the past! The same holds for Phrenic Nerve damage.
PFA is Tissue Selective: Instead of direct tissue contact as with RF ablation, all that’s necessary with PFA is to position the catheter in proximity to the targeted tissue. Because PFA is tissue selective, it’s easier and faster to make lesions without gaps.

Better for EPs

PFA Allows More A-Fib Patients to be Treated: Because PFA takes so little time, patients won’t have to wait for months to schedule an ablation. EPs will be better able to handle today’s epidemic of A-Fib cases. (One wonders how many PFA ablations a skilled EP will be able to do during a day?)
Better for Health of EPs: PFA may add years to an EP’s career and health. EPs no longer will have to wear those heavy lead shields for long periods of time to prevent fluoroscopy radiation damage.

But Not Ready Yet

It will probably take 3-5 years for PFA to be available for most A-Fib patients.

Reference for this report
Jais, P. et al. Lesion Visualization of Pulsed Field Ablation by MRI in an Expanded Series of PAF Patients. IHU Liryc, University de Bordeaux. AF Symposium 2020 brochure, Abstract AFS2020-37, p. 62.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

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2020 AF Symposium: Pulsed Field Ablation vs RF Ablation: a Study in Swine

2020 AF Symposium Abstract

Pulsed Field Ablation vs RF Ablation: a Study in Swine

by Steve S. Ryan

Background: Pulsed Field Ablation (PFA) is a new treatment for Atrial Fibrillation, but it will probably take 3-5 years to be available for most A-Fib patients.

At this year’s AF Symposium, Dr. Jacob Koruth and others from Mount Sinai Medical Center in New York City presented an abstract and poster session of an ingenious study. They conducted research on pigs to compare Pulsed Field Ablation (PFA) with Radio-Frequency (RF) ablation.

Jacob Koruth, MD

Potential Atrial Esophageal Fistula

Normally when doctors perform a catheter ablation which affects the posterior wall of the left atrium, they do everything they can to make sure they don’t also damage the esophagus which often lies just behind the posterior wall.

In a worst case scenario, damage to the esophagus can produce an atrial esophageal fistula (a hole from the esophagus into the left atrium) which can be fatal. To learn more, see 2018 AF Symposium Live Case: The DV8 Esophageal Retractor.  

Moving the Esophagus to Purposefully Cause Fistula!

RF ablation vs PFA and risk of esophagus damage at A-Fib.com

RF ablation vs PFA and risk of esophagus damage

Dr. Koruth and his colleagues wanted to observe was the risk of esophagus damage during a Pulsed Field Ablation (PFA) versus RF ablation. Because PFA is “tissue-specific”, they wanted to test if surrounding non-heart tissue (the esophagus) would be affected.

The subjects in this study were swine (pigs) that could be examined (dissected) afterwards.

During a normal ablation, doctors move the esophagus as far away as possible from where they are ablating.

In this study, Dr. Koruth and his team used the balloon esophageal deviation device (Manual Surgical Sciences Inc.) in all swine to purposefully move the esophagus as close as possible to the posterior left atrium wall.

They then ablated one group of swine using PFA and the other group with RF energy.

Results: Dissection of the Surrounding Non-Heart Tissue

After 25 days, dissection of the pigs revealed the following results.

The pigs who had the Pulsed Field Ablation suffered no esophageal injury damage. Whereas all the RF ablated swine suffered major esophageal injury (including one fistula).

All RF ablated pigs had major ulcerations. In comparison, none of the PFA pigs had any esophageal lesions.

Photos of Dissection: If you want to see the dissection photos comparing the tissue from the PFA vs RF ablation pigs, click on the tab below.

Dissection photos of PFA and RF ablations on swine

Views of esophageal changes at sacrifice 25 days post ablation. A: After pulsed field ablation (PFA), representative images demonstrating the normal luminal (interior) and adventitial (outer) surface of the esophagus. B: After RF ablation, a perforating ulcer and fistula is seen on the luminal (interior) part of the esophagus.

Close-up views of tissue dissected after RF ablation. A: Shows ulceration (top arrow) and perforation (center arrow) from RF ablation. B and C show partially healed ulcerations/lesions from RF ablation.

Editor’s Comments:

These Pulsed Field Ablation results are possible because PFA is “tissue-specific” and doesn’t affect surrounding non-heart tissue (such as the esophagus). It’s an incredible improvement in the treatment of A-Fib.

Pulsed Field Ablation (PFA) will eliminate the most dreaded complication of catheter ablation―Atrial Esophageal Fistula (heat damage to the esophageal from the catheter). Though a very rare complication (around 1 in 2000 cases), it’s unique in that it can kill you or result in major health problems in those who survive.

With PFA, patients and their EPs performing catheter ablations will no longer have to worry about creating these lethal Fistulas. This may be the most significant feature of PFA for Atrial Fibrillation.

It would be hard to imagine a more convincing demonstration! Kudos to Dr. Koruth and his colleagues for this study.

Reference for this article
Koruth, Jacob et al. Pulsed Field Ablation vs Radiofrequency Ablation: Esophageal Effects in a Novel Preclinical Model, Abstract AFS2020-51 p51. AF Symposium 2020 digest publication.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

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AF Symposium 2020: For A-Fib Patients Under Age 40: Genetic Testing Before Your Catheter Ablation?

AF Symposium 2020

For A-Fib Patients Under Age 40: Genetic Testing Before Your Catheter Ablation?

by Steve S. Ryan

Patrick Ellinor, MD

Patrick Ellinor, MD

Background: We have previously reported on the extraordinary work of Dr. Patrick Ellinor of Massachusetts General Hospital and his colleagues world-wide in examining the genetics and genome sequencing of A-Fib, and the genetic susceptibility to A-Fib. This group has been doing genetic testing of A-Fib for over 25 years at over 60 sites throughout the world. (See AF Symposium 2017 World-Wide Studies on Genetic A-Fib)
Gene vs Genome: A gene is a part of a DNA molecule; The genome is the total DNA in a cell.

Over the years, researchers have identified 100 distinct genetic loci for A-Fib. (A locus is a specific, fixed position on a chromosome where a particular gene or genetic marker is located.)

Finding the Genome for A-Fib

In a presentation entitled “AF Under Age 40―Genetic Testing Before Ablation?”, Dr. Ellinor of Massachusetts General Hospital described what is perhaps the culmination of years of work―the discovery that the muscle protein titin-gene (TTN mutation) is the main gene linked to genetic A-Fib.

This is major news! All these efforts by Dr. Ellinor and his many colleagues throughout the world have finally paid off.

Loss-of-function mutation: A mutation that results in reduced or abolished protein function.

The Titin gene is critical for normal heart function. It’s the largest gene in the human genome. About one out of 250 people carries a Loss-Of-Function (LOF) mutation in one of their TTN genes.

In a recent study which examined genome-wide associations in 1,546 people with A-Fib and 41,593 controls, 14% of people who have this mutation have A-Fib. No other gene locus even comes close (see blue arrow in chart below). These TTN mutations have been associated with early-onset A-Fib.

Caption: High-confidence loss-of-function (LOF) variants in TTN among atrial fibrillation (AF) cases and controls cases in UK Biobank. Source: Choi, S. H.

Patients with TTN Mutation Much More Likely to Develop A-Fib

Dr. Ellinor described “finger printing” of a few hundred thousand genetic variants scattered throughout the genome. These capture about 90% of the differences between any one of us.

Having the TTN mutation gives you a six-fold increased chance of developing A-Fib.

His studies compare associated regions and look for spikes such as the TTN mutation. People with the TTN mutation have a six-fold increase in the likelihood of developing A-Fib.

There is also a much smaller TTN association with heart failure and cardiomyopathy. They have done cardiac MRIs on many patients with the TTN mutation.

What Do We Do with This TTN Data?

Dr. Hugh Calkins from Johns Hopkins asked the question on everyone’s mind.

“Now that we have this TTN data, what do we do with it?”

Dr. Ellinor described very preliminary research where they divide patients into low, medium and high risk, then document how the patients do after their catheter ablation.

One might speculate that catheter ablation results with high risk patients wouldn’t be as successful. But right now, this is speculation.

Patients Need to Know If They Have the TTN Gene Mutation

So, will doctors tell their patient if they are at high risk of developing A-Fib? Most patients would want to know.

Popular genetic testing companies include Ancestry and 23andMe.

Dr. Ellinor advises his patients that genetic testing companies offer testing for the TTN mutation as part of an “arrhythmia test” panel for around $100.

Perhaps, patients already diagnosed with early-onset A-Fib would benefit from knowing if they have the TTN mutation.

For patients with the TTN mutation: Your doctor could perform a cardiac MRI and more closely examine and monitor your results. In addition, your children could be tested for the TTN mutation.

The Bottom Line for Patients: Dr. Ellinor recommends genetic testing early and offered to anyone 40 years old or younger with A-Fib.

Added 5/18/21:

Dr. David Darbar of the Un. of Illinois, Chicago states that the Titin gene. associated with an increased risk of atrial fibrillation, poses a significantly increased risk for heart failure in Black and Hispanic/Latinx people.

Editor’s Comments:

Finding the TTN gene/genome responsible for so much A-Fib is a hugely important discovery!
And equally important is finding out that so many people have the TTN LOF mutation. The TTN mutation may cause or make it more likely that someone will develop A-Fib. This is invaluable information both for patients and for the doctors treating them.
But how this TTN information can or will be used in treating patients is a whole new, barely explored world.
A great deal of work lies ahead to better understand the precise mechanisms by which genomic variation causes Atrial Fibrillation.

Participate in A-Fib Genetic Studies

If you and at least 3 other members of your family have A-Fib, you can become involved in this potentially very important research. Contact the studies at Mass. General Hospital or Vanderbilt University.

Patrick T. Ellinor, MD, PhD, Director, Cardiac Arrhythmia Service
Marisa Shea, RN,  Research Nurse
Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
617-724-7780, Email: mshea1(at)partners.org

Vanderbilt University also welcomes families with A-Fib for their genetic studies. Contact the Vanderbilt Atrial Fibrillation Registry (they also have an AF Ablation Registry)

Diane Crawford, RN
Vanderbilt University Medical Center, 1266 MRB IV, Nashville, TN 37232-0575
(615) 322-0067, Email: Diane.n.crawford(at)vanderbilt.edu

References for this article
Choi, S. H. et al. Monogenic and Polygenic Contributions to Atrial Fibrillation Risk, Results From a National Biobank. Circulation Research. 2020 Jan 17;126[2]: 200-9. https://www.ahajournals.org/doi/pdf/10.1161/CIRCRESAHA.119.315686

Choi, S. H. et al. Association Between Titin Loss-of-Function Variants and Early-Onset Atrial Fibrillation. Jama Network, December 11, 2018. https://jamanetwork.com/journals/jama/fullarticle/2718069?resultClick=1

Parmet, Sharon. New mutation raises risk for AFib, heart failure for people of color. UCI Today, May 5, 2021. https://today.uic.edu/new-mutation-raises-risk-for-afib-heart-failure-for-people-of-color

Darbar. F. et al. Association of Rare Genetic Vriants and Early-Onset Atrial Fibrillation in Ethnic Minority Individuals. JAMA Cardiol. May 5, 2021. https://jamanetwork.com/journals/jamacardiology/article-abstract/2779632. doi:10.1001/jamacardio.2021.0994.

 

 

2020 AF Symposium Abstract: PFA+CTI Lesions Terminates Flutter in a Small Study

2020 AF Symposium Abstract

Pulsed Field Ablation With CTI Lesions Terminates Flutter in a Small Study

Illustration of right atrium, cavotricuspid isthmus (CTI) and tricuspid valve annulus.

Definition: Cavotricuspid isthmus (CTI) is part of the right atrium located between the inferior vena cava (IVC) ostium and the tricuspid valve.

Typical Atrial Flutter comes from the right atrium and is usually terminated by what is called a Cavo-Tricuspid Isthmus (CTI) lesion ablation line which blocks the Flutter. But for a CTI lesion to work, the Electrophysiologist (EP) using RF has to make small continuous lesions which require intense concentration to be gap free.

Even though a CTI lesion is one of the safest ablation procedures, there are some risks. Damage can be to the right coronary artery or to the AV Node and His bundle signal pathways.

PFA Makes Flutter Ablation Easier and More Effective

Ante Anic, MD, U. Hospital Center, Croatia

An abstract distributed at the 2020 AF Symposium by Dr. Ante Anic showed how the use of Pulsed Field Ablation (PFA) may significantly improve CTI ablation lesions.

Pulsed Field Ablation is fast, contact forgiving, and only affects cardiac muscle cells (cardiomyocyte).

In a small PFA study (3 patients), a continuous, non-conducting line of CTI lesions was made with a deployable 4-spline, multi-electrode basket-shaped tip catheter.

Study Results: Right atrium Typical Flutter was successfully blocked with bidirectional block (BDB) confirmed. Moreover, these CTI lesions required little time to make (3, 4, & 6 minutes).

Unlike with standard radio-frequency (RF), the Pulsed Field Ablation catheter required few ablation sites (4, 3, and 6 respectively). In effect, making a CTI ablation line with PFA was much easier and required much less precision and concentration.

After a 15 minute waiting period, bidirectional block (BDB) was confirmed in all three patients to make sure there were no Flutter signals. They also used adenosine in one patient to try to stimulate that patient back into Flutter with no success.

Overall, they found that the PFA lesions were persistent and completely blocked the Flutter.

Editor’s Comments:
Pulsed Field Ablation (PFA) has different catheter shapes which enable the operator (EP) to easily work in all areas of the heart.

PFA catheter shapes: (L) Basket catheter (R) Flower Petal catheter.

In this limited study, a Cavo-Tricuspid Isthmus (CTI) lesion was used to eliminate typical Atrial Flutter. The electrophysiologist (EP) used a basket configuration to make linear, focal lesions. PFA seems well suited to any heart configuration an EP may encounter.
Furthermore, EPs don’t have to worry about precisely positioning the PFA catheter for direct contact. Proximity is all that’s needed. PFA is fast and tissue specific. It won’t damage surrounding nerves and organs.
Though a small study, this abstract from Croatia opens up new frontiers for the use of PFA.

I see Pulsed Field Ablation (PFA) as a radically superior treatment for right atrium typical Flutter.

Reference for this article
Antic, A. et al. Acute Experience with Pulsed Field Ablation for Typical Flutter. University Hospital Center Split, Croatia. AF Symposium 2020 brochure, AFS 2020-26, p. 51.

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2020 AF Symposium Abstract: Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study

2020 AF Symposium Abstract

Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study

To better understand this report you should read it in conjunction with my report of Dr. Reddy’s pre-recorded video entitled, Pulsed Field Ablation (PFA) for AF.

This abstract, distributed at the AF Symposium, details a small preliminary study by researchers at Mount Sinai Hospital in New York. They investigated whether Pulsed Field Ablation (PFA) lesions last over time.

We know that Pulsed Field Ablation (PFA) makes safe and durable lesions around the Pulmonary Veins and it produces a zone of irreversible electroporation and cell death. We also know that surrounding this ablated area is a zone of reversible electroporation and cell injury that normalizes over time and turns back into normal tissue.

This study asked whether the level of electrical isolation after PFA regressed over time.

Comparing PFA Ablated Areas with Non-PFA Ablated Tissue

In this clinical trial, detailed voltage maps were created immediately after PFA and again after 3 months. They basically compared the areas of left- and right-sided PV antrum isolation with the non-ablated posterior wall area and, more importantly, with the borders between these two areas.

Results and Conclusion

After 3 months, the ablated areas remained isolated and the non-ablated areas stayed non-ablated. The distances between the borders remained the same.

The authors concluded that PFA isolation persists without regression.

Editor’s Comments:
Since Pulsed Field Ablation (PFA) is such a new treatment, the question of whether PFA electrical isolation regresses over time needed to be asked.

This small preliminary study confirms what we would expect. PFA isolation makes safe and durable lesions that lasts over time.

References for this article
Kawamura, I. et al. Do Pulsed Field Ablation Lesions Regress Over Time?―A Quantitative Analysis of the PVI Level of Isolation in the Acute and Chronic Settings. Ichan School of Medicine at Mount Sinai. AF Symposium 2020 brochure, Abstract AFS2020-54, p. 78.

Graphic source: Maor, Elad et al. Pulsed electric fields for cardiac ablation and beyond: A state-of-the-art review. Heart Rhythm, Volume 16, Issue 7, 1112 – 1120.

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AF Symposium 2020: Live Case of Difficult A-Fib Ablation of Atypical Flutter

2020 AF Symposium

Live Case of Difficult A-Fib Ablation of Atypical Flutter

by Steve S. Ryan

Atypical Flutter circuits can be the most difficult to map and ablate. This live case of Atypical Flutter was a very difficult and challenging ablation. It was certainly among the toughest situations electrophysiologists (EPs) will encounter.

This live catheter ablation from Boston was presented via streaming video. We observed Atypical Flutter during this live ablation.

A-Fib Patient History

Kevin Heist MD

Kevin Heist MD

Dr. Kevin Heist from Massachusetts General Hospital described the patient as a 73-year-old man who had A-Fib and Flutter for 13 years. The antiarrhythmic drugs, dofetilide (Tikosyn) and flecainide, were unsuccessful.

In 2007 he had a successful right atrium Flutter ablation at an outside facility (not Mass. General).

In 2009, while on warfarin, he suffered a spontaneous subdural hemorrhage (bleeding between the brain and the skull) while at work. Fortunately, he lived through it.

In 2013 he had his Left Atrial Appendage closed off by a Lariat device, though they found he still had a small stump of the LAA (which is common after lariat closure).

In 2018 he had a catheter ablation for persistent A-Fib. His Pulmonary Veins (PVs) and his posterior left atrial wall were ablated which terminated his A-Fib, but left him in Mitral Annular Flutter. They ablated extensively particularly in the Coronary Sinus. Finally, they were able to convert him from Flutter to normal sinus rhythm (NSR) by making a Mitral Isthmus ablation line.

2018 Mapping Data was Re-Processed and Updated

The Carto-3 mapping system from Biosense Webster with Smart Touch catheter

Dr. Heist showed the patient’s 2018 mapping. Then he used the new Biosense Webster Carto-3 mapping system with a Smart Touch SF catheter. It can accommodate more points than the traditional system, “it creates a best fit for arrhythmia mechanism.”

He showed the 2018 vectors around the Mitral Annulus which were re-processed through the current Carto mapping system. This electroanatomical system created vectors which showed both directionality and the speed of travel.

Targeted Ablation of Scarring and Reconnection

When Dr. Heist and his team started their initial voltage and activation mapping, they found that a portion of the left vein and the posterior left atrial wall had reconnected, and there was activation of the atypical flutter around the mitral annulus.

They found a portion of the left vein and the posterior left atrial wall had reconnected
In addition, they found passive activation of the left pulmonary vein from that flutter as it traveled across the mitral isthmus line into the left veins posteriorly. They directed their ablation to that point.

With voltage mapping they found quite a bit of scar in the rightward of the posterior wall and quite a bit of scar in the Mitral Isthmus region, but a small channel for activation of the pulmonary vein.

Dr. Heist said: “These advanced mapping systems give you a pretty clear ideas of breakthrough areas. So, we targeted our ablation to isolate the left vein and the posterior wall.” This Flutter seemed to be traveling around the Mitral Annulus and through the Coronary Sinus.

“These advanced mapping systems give you a pretty clear ideas of breakthrough areas.” – Dr. Kevin Heist 

At this point in the procedure, Dr. Heist described his plan to continue to move on to more ablation and if necessary, to Coronary Sinus ablation as was done in 2018 to achieve Mitral Isthmus block.

“We have moved to higher energy and shorter duration lesions and are using 50 Watts for 10-15 seconds commonly to perform typical pulmonary vein isolation. But here we may need deeper lesions than for the rest of the left atrium. We will use 40 Watts with a force of 10 or 15 grams. We’ve been using the lesion index and trying to reach lesion indexes in the range of 500.” (The ablation index is a marker or measure of ablation quality that incorporates power, contact force, and time in a weighted formula.)

Why No Use of Pacing?

Dr. Heist didn’t want to use pacing (entrainment) because he didn’t want to prematurely terminate the Flutter signal. Around this time, they saw some esophageal warming and had to limit their ablations.

Atrial Flutter Termination!

We watched as they actually terminated the Atypical Flutter!

Success! The patient’s atypical Atrial Flutter was terminated.

Nonetheless, Dr. Heist said they would continue the ablation in the Coronary Sinus and the Mitral Isthmus line. They might also ablate circumferentially around the Coronary Sinus to make sure there are no potentials present.

As the ablation team continued to ablate in the Coronary Sinus, they answered questions from the Symposium attendees. They then had to end the live case presentation because of time constraints.

Editor’s Comments:
This ablation procedure for Atypical Flutter has got to be one of the most difficult ablation cases I’ve ever seen performed live! Dr. Heist did everything possible to check for hidden or latent arrhythmia signal sources (a characteristic of a “master” EP).
In an email to the me after the AF Symposium, Dr. Heist shared:

• At the end of the procedure, all pulmonary veins and the left atrial posterior wall were isolated.

• The mitral isthmus through which the atypical flutter had passed was completely blocked (and remained blocked when the IV drug adenosine was given).

• No arrhythmia (flutter or fibrillation) could be induced by aggressive rapid pacing. That’s the best possible result for a patient! 

One can’t help but admire Dr. Heist’s and his colleagues’ tenacity in searching for and ablating this patient’s elusive atypical Flutter.

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2020 AF Symposium: Pulsed Field Ablation—A Game Changer for A-Fib

This year’s AF Symposium was abuzz about an emerging technology, Pulsed Field Ablation (PFA). It could change everything in the field of catheter ablation for Atrial Fibrillation.

Pulsed Field Ablation and how it works was presented by Dr. Vivek Reddy of Mount Sinai Medical Center, NY, NY. He also narrated a video showing an actual Pulsed Field Ablation procedure.

What is Pulsed Field Ablation? Pulsed Field Ablation (PFA) from Farapulse, Inc. is a non-thermal energy system that uses a series of ultra-short electrical pulses to ablate heart tissue. This series of pulses, or the “waveform”, makes a long-lasting lesion in a manner of seconds compared with hours for radiofrequency.

More importantly, PFA works on the selected cell types while leaving others alone (like the esophagus).

Proximity Not Actual Contact: Unlike standard ablation energy sources such as RF (heat) and Cryo (freezing), the PFA 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. …click for full report on PFA.

2020 AF Symposium: Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation

2020 AF Symposium

Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation

by Steve S. Ryan, Updated June 15, 2021

This article on Pulsed Field Ablation (PFA) may be challenging to read. But it’s worth it. As an emerging technology, there are many concepts and treatment strategies that will be brand new to you (they were for me). I expect PFA will change the way catheter ablations are done and will become an innovative and most effective treatment option for A-Fib.

The video presentations at the AF Symposium are always well attended. Usually these cases are presented live via streaming video. But this time the case was a pre-recorded video.

This emerging technology, Pulsed Field Ablation, and how it works was presented on video by Dr. Vivek Reddy from Mount Sinai Medical Center in New York City and by Dr. Petr Neuzil from Homolka Hospital in Prague, Czech Republic.

Dr. Reddy provided live commentary from the podium while the recently recorded patient procedure played on the screen behind him.

Pulsed Field Ablation (PFA) and Electroporation

Pulsed Field Ablation (PFA) from Farapulse, Inc. creates an instantaneous electrical field to open tiny doors (nanopores) in nearby cells, a process called ‘electroporation’ (electro-POR-ation).

Electroporation is a microbiology technique in which an electrical field is applied to cells in order to increase the permeability of the cell membrane.
Shortly thereafter, the contents of the cell exit through these doors and the cell dies.

Unlike current methods of ablation (i.e., radiofrequency and cryo) which rely on cooking or freezing tissue, PFA retains the cell’s original structure even after death and does not rely on thermal effects.

More importantly, PFA works on the selected cell types while leaving others alone.

Video Presentation: Pulsed Field Ablation Case

On the video, we saw Dr. Reddy use fluoroscopy to move the Farapulse catheter (Farawave) to the opening of the Left Superior Vein, a position similar to where one would place a balloon catheter.

Farapulse Five Petal Flower at A-Fib.com

Farapulse catheter: Five Petal Flower Configuration

The configuration of the catheter looked like a flat five-petal flower. He was also able to change the configuration to a more spherical “basket” shape. Each of the five splines contained four separate electrodes which delivered the PFA energy. The fully deployed flower-shaped configuration had a diameter of 31 mm.

Those same electrodes that delivered the PFA energy also recorded signals from the heart to show that the ablation was effective. They could switch back and forth during the ablation procedure.

Direct Contact Not Necessary

We watched how they delivered one application of PFA, then 10 seconds later they rotated the five-spline catheter a few degrees and delivered another application to optimize coverage and proximity.

Farapulse catheter: Open-Basket Configuration at A-Fib.com

Farapulse catheter: Open-Basket Configuration

Dr. Reddy explained that they perform two paired deliveries with the basket configuration, then two more with the flower configuration with occasional rotation of the catheter. They didn’t seem to worry about achieving direct, hard contact with the Pulmonary Vein (PV) openings.

Someone from the audience asked, “How much contact do you need?” Dr. Reddy replied, “You definitely need proximity. Do you actually need  contact? No. But you need proximity, to be within a couple of millimeters of the targeted tissue.”… “We’re not going to cause PV stenosis with this.”

We saw how the electrograms of A-Fib signals disappeared as the PFA applications progressed. The application process seemed to move very fast. Dr. Reddy stated that he could vary the size and shape of the configurations to fit individual anatomies.

Affects Heart Tissue but Not the Esophagus

Dr. Reddy added (enthusiastically),“What is really exciting about it is tissue selectivity.” He talked about how each tissue seems to have a different threshold for necrosis (cell death) which makes PFA very tissue selective.

PFA can affect heart tissue (cardiomyocytes) while not affecting nerve fibers or the esophagus. We watched as he ablated the Right Superior PV which seemed very close to the Phrenic Nerve. Dr. Reddy described how in 120 cases to date, he has never seen Phrenic Nerve paralysis or even palsy.

Left-RF ablation with damaged Esophagus; Center-CryoBalloon ablation with damaged Esophagus; Right-Pulse Field ablation with Normal Esophagus. Source: Dr. Vivek Reddy

Posterior Wall Ablation

Using the flower configuration, Dr. Reddy then ablated the posterior wall by simply making overlapping flower-shaped petal lesions, two sets of lesions in each location. This also seemed to go very fast.

Cavo-Tricuspid Isthmus Line

He also showed how he made a Cavo-Tricuspid Isthmus line (to ablate Flutter from the right atrium) by switching to a catheter with a small basket used as a focal catheter.

After the video ended, Dr. Reddy said they have already performed 126+ ablations using PFA. (Certainly seems ready for ‘prime time’.)

Characteristics of Pulsed Field Ablation (PFA)

Tissue Selective and Safer

The underlying process of Pulsed Field Ablation called “Irreversible Electroporation” is tissue selective. Cardiomyocytes (heart tissue) happen to have a particularly low threshold to these electrical fields which don’t affect other surrounding non-heart tissue such as the esophagus or phrenic nerve. In practical terms, this means that PFA is much safer than current ablation energy sources.

Very Fast and Precise

Pulsed Field Ablation is a non-thermal energy system that uses a series of ultra-short electrical pulses to ablate heart tissue. This series of pulses, or the “waveform”, makes a long-lasting lesion in a manner of seconds. PFA can be  delivered in seconds or minutes compared with hours for radiofrequency.

PFA is not only very fast but very precise as well. The Farapulse generator, which creates the waveform, can be programmed to deliver therapy through different PFA catheters.

Doesn’t Require Direct Contact

PFA catheter does not require actual physical contact but only needs proximity to the tissue.

Unlike standard ablation energy sources such as RF (heat) and Cryo (freezing), the PFA 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.

Doesn’t Produce Stenosis

Clinical trials have shown that direct application of PFA to pulmonary veins does not seem to result in PV stenosis (swelling) which can occur from heating (RF) or cooling (cryo).

FDA ‘Breakthrough Device’ Designation for PFA

U.S. Food and Drug Administration logoThe FDA gave PFA (Farapulse, Inc.) their Breakthrough Device designation May 8, 2019. This FDA Program is designed to “help patients receive more timely access to breakthrough technology which has the potential to provide more effective treatment and diagnosis for life-threatening or irreversibly debilitating diseases and  conditions.”

Translation: The FDA recognized how PFA can potentially change the nature of catheter ablation and become a major innovative improvement in the treatment of patients with A-Fib.

PFA Ablation: A Few Years Away for A-Fib Patients

As Dr. Jais and others commented at the end of the presentation, it will probably take 3-5 years for PFA to be available for A-Fib patients worldwide.

This estimate was way too conservative. Farapulse has already received CE Mark approval and can market in the Europeans Union and other CE Mark countries. -SSR. June 2021

Assuming eventual FDA approval (very likely), the small start-up company Farapulse, Inc. will probably have to be bought by a major device manufacturer with a world-wide manufacturing, marketing and distribution network. That’s probably the only way to produce and distribute the Farapulse Pulsed Electrical Field generators in quantities sufficient to treat large numbers of A-Fib patients.

Disclosure: Dr. Vivek Reddy of Mount Sinai Medical Center in New York city has invested in and owns stock in Farapulse, Inc. This is an indication of the confidence he has in PFA technology.

Editor’s Comments

Note: All forward-looking statements and claims regarding safety and effectiveness are those of the author alone.
PFA Ablation: A True Game Changer: Everyone at the AF Symposium was in awe at how fast, easy and effective PFA ablation seemed to be.
I predict that Pulsed Field Ablation will supersede all other types of catheter ablation for A-Fib. But it will probably take 3-5 years for PFA ablation to become standard and available for most A-Fib  patients.
Update: June 2021: This estimate was way too conservative. Farapulse has already received CE Mark approval and can market in the Europeans Union and other CE Mark countries. In the U.S.. the ADVENT Trial, is underway with the first patients treated at New York’s Mount Sinai Hospital by Vivek Reddy, M.D.
But Don’t Wait for PFA: If you are asking yourself if you should wait 3-5 years for PFA ablation to be available, the answer is no. Today’s ablation techniques are very good and effective, though not apparently as good as PFA. And waiting 3-5 years for an ablation could do serious harm to your heart.
In fact, read about my second Ablation in 2019, 20 years after the first.
Thanks to Farapulse, Inc who provided technical content and images for this report. For anyone interested in investing in PFA and Farapulse, Inc., it’s a privately held company with no stock currently available.

Read More About Pulsed Field Ablations (PFA)

See my summaries of five abstracts (one-page descriptions of A-Fib research) distributed at the Symposium as a printed digest.

• Lesion Durability and Safety Outcomes of Pulsed Field Ablation

• Pulsed Field Ablation with CTI Lesions Terminates Flutter in a Small Study

• Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study

• Pulsed Field Ablation vs RF Ablation: A Study in Swine 

• Using MRI to Check Pulsed Field Ablations (PFA)

If you find any errors on this page, email us. Y Last updated: Tuesday, June 15, 2021

Return to 2020 AF Symposium Reports

AF Symposium 2020: My New A-Fib Reports

This year the 25th AF Symposium was held January 23-25th in Washington DC (for this fellow from Malibu it was cold but no snow ).

Atrial Fibrillation: I attended over 75 presentations including Spotlight (short) sessions, learning luncheons and panel discussions with Q/A. The Symposium lets me learn about advances in research and treatments of A-Fib directly from the most eminent medical researchers, scientists, cardiologists and cardiac electrophysiologists.

There are many interesting topics including the controversy of closure of the Left Atrial Appendage. But the many presentations about the new “Pulsed Field Ablation” technology dominated the Symposium.

Read My First Report: Overview: The 25th Annual International AF Symposium 2020 by Steve S. Ryan, PhD

Steve Ryan at 2020 AF Symposium in Washington DC in January.

Steve Ryan at 2020 AF Symposium in Wash, DC.

More reports are coming: I’ve finished a number of my summary reports and will be posting several each week.

Check the menu list on the left for 2020 AF Symposium and click to go to my latest posts.

Remember: All my reports are written in plain language for A-Fib patients and their families. (I’ve done the heavy lifting for you!)

P.S. You may want to browse my reports from the 2019 AF Symposium or the archive to my AF Symposiums Summaries by Year.

2020 AF Symposium: Reports for Patients by Steve S. Ryan, PhD

AF Symposium 2020

My Summary Reports Written for A-Fib Patients

by Steve S. Ryan, PhD

Now in its 25th year, the annual AF Symposium is one of the most important scientific conferences on A-Fib in the world. (I attended my first AF Symposium in 2003.)

Each year at the Symposium, I learn about advances in research and treatments directly from the most eminent medical researchers, scientists, cardiologists and cardiac electrophysiologists. 

As always, I do this 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.

REPORT TITLEPRESENTER (S)DATE POSTED
21.Live Case: Ablation using the AcQMap 3D Imaging, Mapping and Navigation System
Dr. Timothy Betts of Oxford Un. Hospitals, UK. January 10, 2020
20.Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart PauseDr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, INMay 2,2020
19.Abstract: Combination Device to Both Electrically Isolate and Occlude the Left Atrial Appendage (LAA)John Thompson, MD, MBA, MSC AuriGen MedicalMay 1, 2020
18.Abstract: High Hemorrhagic Risk Factors from NOACsMassachusetts General HospitalMay 1, 2020
17.Terminate Persistent A-Fib by Ablating Higher Frequency Modulation AreasDr. Jose Jalife, University of Michigan, Ann Arbor, MIMay 1, 2020
16.Protecting the Esophagus by Cooling ItDr. Mark Gallagher from St. George’s University Hospital in London, United KingdomApril 28, 2020
15.For A-Fib Patients Under Age 40: Genetic Testing Before Your Catheter Ablation?Dr. Patrick Ellinor of Massachusetts General HospitalApril 28, 2020
14.After Diagnosis, How Soon Should an A-Fib Patient Get an Ablation?Dr. Karl-Heinz Kuck of St. Georg Hospital in Hamburg, GermanyApril 28, 2020
13.Virtual Heart” Assists Actual AblationsProf. Natalia Trayanova of Johns Hopkins Un. in Baltimore, MD.April 26, 2020
12.Device-Detected AF and Stroke Risk as a Function of AF Burden-Clinical Implications Dr. Daniel Singer, Massachusetts General Hospital in Boston, MAApril 26, 2020
11.Live Case: LAA Closure with New  Watchman FLXDr. John Foran, Royal Brompton Hospital in London, UKApril 24, 2020
10.Live Case: Convergent AF AblationDrs. Andrew Makati and Andrew Sherman, St. Joseph’s Hospital, Tampa, FLApril 22, 2020
9.Live Case: Ultra-Low Temperature CryoablationDr. Tom De Potter, OLV Hospital, Aalst, BelgiumApril 21, 2020
8.PFA Abstract:
Lesion Durability and Safety Outcomes of Pulsed Field Ablation 
Dr. Vivek Reddy, Mount Sinai Medical Center, New York CityApril 17, 2020
7.PFA Abstract:
Pulsed Field Ablation with CTI Lesions Terminates Flutter in a Small Study
Dr. Ante Anic, University Hospital Center Split, CroatiaApril 17, 2020
6.PFA Abstract:
Durability of Pulsed Field Ablation Isolation Over Time: Preliminary Study 
Researchers at Mount Sinai Hospital in New YorkApril 17, 2020
5.PFA Abstract:
Pulsed Field Ablation vs RF Ablation: A Study in Swine
Dr. Jacob Koruth, Mount Sinai Medical Center, New York CityApril 17, 2020
4.PFA Abstract:
Using MRI to Check Pulsed Field Ablations (PFA)
The French Bordeaux GroupApril 17, 2020
3.Live Case: Difficult A-Fib Ablation of Atypical FlutterDr. Kevin Heist from Massachusetts General HospitalApril 10, 2020
2.Pulsed Field Ablation—Emerging Tech for Atrial FibrillationDr. Vivek Reddy, Mount Sinai Medical Center, New York City, USA; Dr. Petr Neuzil, Homolka Hospital in Prague, Czech Republic.April 6, 2020
1.Overview: The 25th Annual International AF Symposium 2020 by Steve S. Ryan, PhD– – –March 2020
Archive: Link to all my AF Symposiums Summaries by Year

J. Ruskin

“Steve Ryan’s summaries of the 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

If you find any errors on this page, email us. Y Last updated: Monday, June 14, 2021

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