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

2016 AF Report: Predictors of Unsuccessful Ablations: It’s All About Remodeling

AF Symposium 2016

Predictors of Unsuccessful Ablations: It’s All About Remodeling

by Steve S. Ryan, PhD

If someone tells you to “Just live with A-Fib”, or “It’s no big deal,” or “A-Fib’s just a nuisance”, RUN, don’t walk, for a second opinion! Don’t wait—a long enough delay allows atrial remodeling to change your heart and makes it much more difficult to get a successful ablation (i.e. become A-Fib-free).

Predictors of Unsuccessful Persistent A-Fib Ablation

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre, in his presentation “Predictors of Clinical Outcomes in Ablation of Persistent AF Drivers”, found several predictors of unsuccessful ablation outcomes in persistent A-Fib cases. (Drum roll, please.) They are all related to atrial remodeling!

The predictors of unsuccessful outcomes are:

• A-Fib Duration (how long a patient had been in A-Fib prior to ablation)
• A-Fib Cycle Length (the faster the cycle length, the harder to achieve success)
• Number of Drivers (the more drivers mapped, the less chance of success)
• Arial Size (the more the left atrium is extended and stretched, the less chance of success)
• Fibrosis (being in A-Fib normally produces fibrosis)

Dr. Haissaguerre of Central Hospital, Bordeaux, France, used slides to explain his findings. (You may want to read this article together with Dr. Haissaguerre’s other presentation: Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation.)

“Reentries” are Short Lived But Recur in the Same Region

Dr. Haissaguerre showed images of ECGI/ECVUE Cardio Insight mapping done either the day before the ablation or during the procedure. ECGI produces statistical density mapping of “reentries” (rotors) and focal breakthroughs. These reentries are short lived but periodically recur in the same region.

The Number of Driver Regions

The number of driver regions increases with how long a patient has been in persistent A-Fib. In cases of long-standing persistent A-Fib, he has found as many as 7 driver regions.

Fibrosis and Low Atrial Voltage

Dr. Haissaguerre cited the work of Dr. Marrouche which found decreased ablation success with the extent of fibrosis or atrial low voltage. (For more about Dr. Marrouche’s research, see: High Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation)

Characteristics of Reentries (Rotors)

Dr. Haissaguerre discovered several previously unknown characteristic of rotors:

• Driver domains are part of CFAE areas.
• Core trajectories or rotors are anchored at distinct parts of fibrosis.
• There is a strong link of A-Fib drivers to structural heterogeneities (dissimilar parts like the PVs and LAA opening).

For example, 98% of reentries are found at common points like the Left Pulmonary Vein/Left Atrial Appendage (LAA) area. Whereas focal discharges are mainly observed at the PVs (60% of patients), LAA, or Right Atrial Appendage (RAA).

A-Fib Termination Strongest Predictor of Ablation Success

After 12 months, 85% of patients with A-Fib termination were still free from A-Fib. In the small group of patients who did not achieve termination (and were electrically shocked to try to return them to sinus), 63% were A-Fib free after 12 months. The 37% who remained in A-Fib were all patients with persistent A-Fib.

Ablation Works Best if in Sinus Rhythm Before the Ablation

The A-Fib termination rate was 84% in patients in sinus rhythm at the time of the ablation (with an RF delivery time of only 22 minutes). To get persistent patients in sinus before the ablation, they often would be electrocardioverted.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map ATs. Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”. 68% were from driver regions previously ablated. 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

How to Improve Ablation Outcomes

Dr. Haissaguerre stated that the key to improve ablation outcomes is to minimize atrial remodeling by:

1. Ablate earlier (after only a few months of persistent A-Fib, rather than letting patients go into long term persistent).
2. Restore patients to sinus rhythm before the ablation, especially in cases of longer lasting A-Fib.
3. Manage risk factors such as by using preventive drugs.

He showed slides of how flecainide reduced crucial driver regions, and how amiodarone both lengthened cycle length and decreased driver regions.

Dr. Haissaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers in a more specific way than other current approaches
• There’s a strong link of driver locations with structural heterogeneities (anatomical junctions and fibrosis)
• Predictors of clinical outcome—AF Duration, A-Fib Cycle Length, Number of Drivers, Atrial Size, Fibrosis―mainly relate to Atrial Remodeling with obvious practical implications

What Patients Need to Know

Don’t Live in A-Fib! The message for patients from Dr. Haissaguerre’s presentation is fairly obvious—Don’t settle for a life in A-Fib! A-Fib is a progressive disease that usually gets worse over time. It produces remodeling of the left atrium.

Don’t Stay in A-Fib! A delay in treatment makes it much more difficult to have a successful ablation!

Danger of a Fibrotic Heart—Fibrosis: Most of the remodeling effects of living in A-Fib can be corrected or improved by a successful catheter ablation. But not fibrosis! (Which is generally considered permanent and irreversible).

Fibrosis produces collagen and scarring in the heart which is a permanent remodeling effect of A-Fib. Fibrotic tissue is scarred, immobile, basically dead tissue with reduced or no blood flow and no transport function. It results in a loss of atrial muscle mass. Over time it makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems. Read more about fibrosis in my article: A-Fib Produces Fibrosis—Experimental and Real-World Data.

Remodeling Makes Catheter Ablation More Difficult:  A successful ablation is much more difficult when your heart has been remodeled by A-Fib. Patients with Long-standing A-Fib develop as many as seven different driver regions, compared to only two in patients who were in Persistent A-Fib for only a couple of months. Even the ‘great’ Bordeaux group couldn’t cure all of these cases.

Ground-Breaking Discoveries Important for Patients

1―Ablation works best if you are in Sinus Rhythm BEFORE the ablation.
This principle is not yet generally understood and practiced by the EP community. As a patient you should seek out EPs who will try to get you back into sinus before your ablation.

Ask the EP you are interviewing, “Will you try to get me back into sinus rhythm before the ablation?” How will you do this?” They should answer that they will use Electrocardioversion and/or antiarrhythmic drugs to do this, particularly in cases of persistent A-Fib.

For example, one A-Fib patient emailed me that the Mayo Clinic Electrocardioverted her into sinus, then used Tikosyn to keep her in sinus for a month or two before her ablation.

2―A-Fib termination is the strongest predictor of ablation success.
This discovery is very important for patients. Some previous research said that it really didn’t matter if A-Fib terminated during the ablation.

Nevertheless, in Dr. Haissaguerre’s research, 84% of patients with A-Fib termination during the ablation procedure were still free of A-Fib after 12 months.

The Bottom line for Patients

A-Fib termination during the ablation procedure should be the goal of every EP. You should seek out EPs who will make that extra effort (such as replacing the CryoBalloon catheter with a RF catheter to isolate non-PV triggers). All too many EPs aren’t willing or aren’t able to do that.1

Dr. Michel Haïssaguerre

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

Citations for this article
Haissaguerre, M. et al. Driver Domains in Persistent Atrial Fibrillation. Circulation. 2014;130:530-538. http://circ.ahajournals.org/content/130/7/530.short. doi: 10.1161/CIRCULATIONAHA.113.005421

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Saturday, February 16, 2019

Footnote Citations    (↵ returns to text)

  1. I recently read an O.R. report where the EP used CryoBalloon ablation on a patient in persistent A-Fib for two months. They successfully isolated the patient’s Pulmonary Vein openings (PVs), but the patient was still in A-Fib. Instead of trying to map and isolate the patient’s non-PV triggers which were still producing A-Fib signals, the EP simply shocked the patient back into sinus rhythm. After a few weeks, the patient was back in A-Fib again. (But to be fair to the EP, sometimes this is successful.)

2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts

AF Symposium 2016

Six Live Catheter Ablations—Watching the Experts

by Steve S. Ryan, PhD

2016 AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

2016 AF Symposium 5-floor-to-ceiling video monitors

Watching LIVE catheter ablations on floor-to-ceiling display screens was one of the most interesting and exciting features of the AF Symposium. “Case Studies: Catheter Ablation for Atrial Fibrillation” featured live streaming video (transmitted via the internet rather than by satellite as in previous years).

The six ablations were streamed live from:Live Streaming Video from 2016 AF Symposium

• Seoul, South Korea
• Munich, Germany
• Bordeaux, France
• Philadelphia, Pennsylvania
• Austin, Texas
• Boston, Massachusetts

A world-class panel of electrophysiologists (EPs) were able to interact with the EPs doing the ablations and ask questions.

The panelists were: Dr. Moussa Mansour (Co-Moderator), Dr. Jeremy Ruskin (Co-Moderator), Dr. Michel Haissaguerre, Dr. Francis Marchlinsk,i Dr. Andrea Natale, Dr. Douglas Packer, Dr. Vivek Reddy and Dr. David Wilber.1

The Live Cases Begin

Seoul, South Korea: 62-year-old in long-standing persistent A-FibLive Seoul S Korea

Drs. Young-Hoon Kim, Jong-II Choi, JaeMin Shim and their colleagues from S. Korea were all wearing radiation glasses. They were doing a very difficult case of a 62-year-old in long-standing persistent A-Fib for 12 years. He had had a previous ablation. But his A-Fib had recurred five months ago.

His PVs were well isolated. They worked on ablating CFAEs, the right atrium, and the septum which was very fibrotic.

Very unusual: an epicardial ablation (outside the heart) to isolate an A-Fib signal from Bachman’s Bundle.
What was very unusual was they performed an epicardial ablation (outside the heart) to isolate an A-Fib signal they found coming from Bachman’s Bundle. (We didn’t get to actually see that, due to the audio problem.)

When they ablated the Left Atrial Appendage, the A-Fib terminated.

What Was Most Impressive

• Ablating from outside the heart. As far as I know, very few EPs do this. Should every EP receive training in ablating from outside the heart? What’s the best way of discovering and mapping A-Fib signals coming from the exterior of the heart, such as from Bachman’s Bundle? (I’ve written the S. Korean EPs to ask them these questions.)

• Successfully ablating and terminating A-Fib in someone who had been in long-standing persistent A-Fib for 12 years. This is usually the most difficult kind of case and the hardest to cure. (Many EPs would consider this long-standing persistent case unfixable and not even attempt a catheter ablation.) It’s no surprise that this was the second ablation for this patient. This case also shows the importance of the Left Atrial Appendage (LAA) in A-Fib ablation.

Munich, Germany: 62-year-old male in long-standing persistent A-Fib and BMI of 35Live Munich Germany

Drs. Isabel Diesenhofer, Felix Bourier and Tilko Reents of the German Heart Center in Munich did an ablation on an unusual case, a 62-year-old male in long-standing persistent A-Fib with a BMI of 35! (Many centers would not accept this patient for an ablation without his first losing weight.)

Dr. Diesenhofer said they don’t use Contact Force sensing catheters because they are too soft. They don’t use TEE but instead use CT to check for clots and to see where the esophagus is in relation to the back of the heart. They perform circumferential PVI.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity.

They were testing a brand new software that combined voltage reading and CFAEs using an enhanced algorithm that measures continuous electrical activity. Their goal is to terminate A-Fib during the procedure, but 70%-80% of these cases come back in Atrial Tachycardia (AT). A second ablation is usually more successful.

They found that the fastest frequencies were coming from the patient’s LAA. When they terminated A-Fib, they used adenosine to test for recurrence.

What Was Most Impressive

• I was surprised that they were doing an ablation on someone with a BMI of 35! The chances of recurrence are huge when someone is obese.

• The use of adenosine after termination of the patient’s A-Fib in order to try to re-induce A-Fib and test for ablation integrity and isolation.

• And, as in the live case from South Korea, this case showed the importance of the LAA in A-Fib ablation, particularly in persistent A-Fib.

Bordeaux, France: 40 year old who went directly into persistent A-FibLive Bordeaux France

Dr. Mélèze Hocini, Bordeaux, France worked behind what looked like a Plexiglas screen with arm holes as a protection against radiation. Her patient was unusual in that he was relatively young, 40 years old, who went directly into persistent A-fib without apparently having paroxysmal (occasional) A-Fib first. He had undergone 3 cardioversions. He was symptomatic, especially dyspnea. He had tried Sotalol and Flecainide.

The day before his ablation, he was mapped with the ECGI/ECVUE Cardio Insight vest. Dr. Hocini showed how the vest mapped four basic areas where there were rotors/focal drivers. She had circled each area and gave each one a priority number from 1 to 4 depending on how many rotors/foci there were in each section.

We watched as she ablated the first area. She ablated at 40 watts for 30 or 40 seconds. The LAA had the highest frequency 167. (In general, they try to slow down the frequency to 200 which usually results in termination.)

An important innovation developed by the Bordeaux group is to re-map during the procedure.

An important innovation the Bordeaux group has developed is to re-map during the procedure. Sometimes new signal areas may appear which need to be ablated. Dr. Hocini, re-mapped, but didn’t find any new signal areas. This patient had many CFAEs (70%). The drivers covered 30% of his left and right atria.

Someone mentioned that the Pentaray mapping catheter was faster and provided better definition than ECGI. Non-PV triggers are often found in the septum, anterior left atrium, coronary sinus, and the left and right appendages. The goal is to slow down the frequency and make the signals more organized.

After a visit with the teams in Philadelphia and Austin, the moderators returned to the group in Bordeaux, France.

Eeveryone was relaxing and happy. While we were away, Dr. Hocini had ablated the third area of rotors/foci which terminated the A-Fib and restored the patient to sinus rhythm.Since the patient was already in sinus, Dr. Hocini didn’t ablate the remaining fourth area of rotors/foci.

What Was Most Impressive

• It was simply amazing to see ECGI/ECVUE in action! To me it looked like I was seeing the future of A-Fib ablation. Dr. Hocini seemed almost nonchalant, like she had done this many times before and was confident it would work. Like many great innovations, using ECGI seemed very simple.

Philadelphia, Pennsylvania:  76-year-old woman with hypertension, persistent A-Fib for five years and previous PVILive Philadephia PA

The moderators then switched to Drs. David Frankel, Pasquale Santangeli, and Gregory Supple at the Un. of Pennsylvania in Philadelphia. They were ablating a 76-year-old woman with hypertension who had been in persistent A-Fib for five years. (Usually a more difficult case.) She had had a Cardioversion in 2014. She was on amiodarone but was still severely symptomatic.

In their experience, ablating only the PVs returns patients to sinus in 80% of all types of A-Fib. They find non-PV triggers in many different sites in the left and right atria. Their protocol is to do a PVI, cardiovert, ablate, then use isoproterenol to induce or re-induce A-Fib triggers.

…a somewhat unusual strategy called “empirical” ablation…Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

This patient also had had a previous PVI, but two of her PVs were re-connected and needed to be ablated. She was restored to sinus rhythm. They then used isoproterenol to try to re-induce A-Fib.

They also employed a somewhat unusual strategy called “empirical” ablation. From their experience, they know that certain sites in the atria tend to produce non-PV A-Fib signals. Even though this patient was no longer in A-Fib/Flutter, they still ablated in these known non-PV trigger sites.

What Was Most Impressive

• “Empirical” ablation (ablating areas known to produce A-Fib signals even though the patient is no longer in A-Fib) is a somewhat controversial strategy. Some would say one shouldn’t scar or burn the heart unless those areas are actually producing A-Fib signals or potentials. Scarring does damage heart tissue. Personally, I would prefer to have them ablate these “empirical” sites as long as they are in my heart anyway.

• In contrast with the Munich, Germany case, the EPs in the Un. of Pennsylvania used isoproterenol to try to re-induce A-Fib rather than adenosine.

Austin, Texas: 83-year-old woman in long-standing persistent A-FibLive AUSTIN TX

The moderators then switched to Drs. Rodney Horton, Amin Al-Ahmad, and J. David Burkhardt at the Texas Cardiac Arrhythmia Center in Austin, TX. They didn’t use any fluoroscopy during their ablation and weren’t wearing the standard-issue lead vests to protect from radiation. They used ICE for navigation.

Their patient was an 83-year-old woman in long-standing persistent A-Fib. Even though she was very symptomatic, she was very active and was scheduled to be married in a couple of weeks. She had been on amiodarone and had failed cardioversions. She had a lot of severe scarring.

They stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA.

They cardioverted her two times without success. After their first ablation, they used isoproterenol to check for re-connection. Two of the PVs had reconnected and had to be re-isolated. Their next step was to isolate the LAA. But they stressed to us the need to discuss with the patient the risk of completely electrically disconnecting the LAA. This patient knew that she could lose her LAA, that later they may have to physically remove it, and that this might affect her.

She still wanted it done so that she could be restored to sinus rhythm. For her it was better long term to be free of A-Fib than to retain a LAA.

They did electrically isolate her LAA and restored her to sinus rhythm, which she hadn’t been in in many years.

What Was Most Impressive

• Though we had seen this last year in the live cases, it was still something of a shock to see EPs, nurses and staff not wearing any protective gear against radiation. (When I visited an A-Fib lab to watch an ablation, I had to wear a very heavy lead vest and other protective gear.) They use ICE instead of fluoroscopy (X-ray) to manipulate the catheters.

• You will notice that this is the third live case emphasizing the importance of the LAA, particularly in persistent A-Fib. They discussed with this patient the possibility that she might lose her LAA. But like most A-Fib patients, she was willing to take that risk to be free of A-Fib

Boston, Massachusetts: 65-year-old male with atypical FlutterLive BOSTON MA

The moderators then switched to Dr. Kevin Heist at Massachusetts General Hospital in Boston. He was working on a case of atypical Flutter. A 65-year-old male patient had been symptomatic for many years. He had tried flecainide. In 2003, he had a PVI. Then in 2010 he had to have a re-do which kept him in sinus rhythm for 5 years. In 2015 he had a cardioversion but still had atypical flutter. His ejection fraction was a very good 75%, but he had mild left atrial enlargement. They found that his PVs and posterior atrium wall were still well isolated.

Biosense Webster PentaRay catheter

The Biosense Webster PentaRay catheter

They demonstrated how to use the PentaRay NAV mapping and ablation catheter (Biosense Webster) to very rapidly map the atrium. It uses a multi-electrode mapping technology. The five branch star design has branches that are soft and flexible so as not to damage the heart surface.

Through pacing, Dr. Heist found a Mitral Annulus Flutter, which he ablated. This terminated the Atrial Tachycardia and restored the patient to sinus.

What Was Most Impressive

• It was fascinating to watch the PentaRay catheter rapidly move by itself over the heart. It kind of looked like a spider crawling along inside the heart. It was amazing how fast the PentaRay catheter reproduced and mapped the heart automatically in high resolution. Very few moves were necessary to map the whole left atrium.

• Is the PentaRay NAV mapping catheter better than the FIRM or ECGI/ECVUE systems? Should one seek out a center using the PentaRay catheter? Right now we can’t say for sure. As far as I know, there haven’t yet been any comparative studies of the PentaRay mapping catheter compared to FIRM or ECGI. Most likely it will eventually be used in combination with FIRM or ECGI. It seems like an important tool and advance in mapping.

That’s a WrapThats a Wrap on TV monitor 215 x 200 pix at 300 res

The co-moderators, Dr. Moussa Mansour and Dr. Jeremy Ruskin (both from Mass. General Hospital, Boston,MA) did a good job moving the program along and kept the interactions with the EP labs personnel on point.

It’s awesome to watch the world’s best electrophysiologists restoring patients to normal sinus rhythm and making them A-Fib-free.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Thursday, February 11, 2016

Footnote Citations    (↵ returns to text)

  1. An audio problem caused a delay at the start of the program. During the wait, the panelists spoke about their work with persistent A-Fib. Dr. Marchlinski said that at the Un. of Pennsylvania 11% of male patients have non-PV triggers while 16% of females have them. (However, he uses a more conservative, stricter definition of an A-Fib trigger.) Whereas Dr. Reddy said that at Mount Sinai Hospital, 30% have non-PV triggers.

    Dr. Vivek Reddy considers the mapping and ablation of non-PV triggers to be the next step in the evolution of catheter ablation of A-Fib. (This is perhaps the most important statement made at this AF Symposium.)

    Both Dr. Reddy and Dr. David Wilber (Loyola, IL) use the FIRM mapping system among other mapping strategies. (ECGI/ECVUE is not currently available in the US.)

Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation

AF Symposium 2016

Bordeaux New ECGI Ablation Protocol—Re-Mapping During Ablation

by Steve S. Ryan, PhD, February 2016

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

CardioInsight ECGI vest-like device with 256 electrodes for 3-D non-invasive mapping

Updated Feb. 2017: The CardioInsight system was approved by the US FDA Feb. 3, 2017 and is being made available to A-Fib centers in the U.S. Dr. Vivek Reddy at Mount Sinai Medical Center in New York City was the first to use the system commercially in the U.S.

Why ECGI/ECVUE is Important

ECGI/ECVUE is probably the most significant, game changing improvement in treating A-Fib (along with Contact Force sensing catheters), particularly for people with persistent A-Fib.

ECGI will not only change the ways mapping and ablations are done, but possibly how you and I are examined and diagnosed in our doctor’s office.

Image a Future Physical Without an EKG

Imagine when you go in for a physical that, instead of getting an EKG, you simply put on an ECGI vest which tells the doctor where and how many A-Fib producing potentials you have in your heart, all without you having to be in A-Fib. Admittedly, this is pie-in-the-sky speculation right now. But the ECGI vest has tremendous potential to change the way A-Fib is diagnosed and treated.

Dr. Michel Haissaguerre & New Uses of ECGI/ECVUE

Dr Haissaguerre

Dr Michele Haissaguerre, The Bordeaux Group

Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France presented new developments in how the Bordeaux group now uses ECGI/ECVUE Cardio Insight body surface mapping for persistent A-Fib. His talk was entitled “Monitoring of AF Drivers During Catheter Ablation for Persistent AF.” (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging [ECG]). See also How ECGI Works.)

Patient Prep with the ECGI Vest

Typically, the day before an ablation, a technician (it doesn’t have to be the EP ablationist) uses a ECGI vest to map and identify sites in the heart producing A-Fib signals (rotors and focal sources). The next day, using this map combined with a CT scan which produces a very detailed 3D color map of the heart, the EP ablates and isolates these sites.

What’s New: Bordeaux Group Also Re-Maps Using the ECGI Vest

What’s brand new about how the Bordeaux group is using ECGI is that, if a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest. This often reveals missed, changed or new A-Fib drivers. They then ablate/isolate these regions.

If a patient’s A-Fib has not been terminated after the ablation, they then re-map using the ECGI vest.

The ideal or goal is for A-Fib to terminate into sinus rhythm or Atrial Tachycardia (AT). Atrial Tachycardia (a heartbeat that is in sinus rhythm but faster than normal) can then also be mapped and ablated into Normal Sinus Rhythm (NSR). (Atrial Tachycardia, for the average persistent patient, feels a lot better than being in A-Fib.)

If after re-mapping and ablation, the patient is still in A-Fib, they use Electrocardioversion to try to shock the patient back into sinus.

See the AF Symposium Live Case Presentations: Dr. Mélèze Hocini of the Bordeaux group ablated a 40-year-old male with persistent A-Fib. She found four areas of rotor/focal activity in his heart. After ablating the third area, the patient’s persistent A-Fib terminated. Dr. Hocini did not have to re-map or ablate the fourth area.)

Slides of Before and After ECGI Ablation

Dr, Haissaguerre showed slides of before and after an ablation using ECGI. Ablation at a driver region transformed rapid, complex signals into slower, organized signals.

In the AFACART study in which eight different centers used the ECGI system, ablations in driver regions varied from 38 to 98 minutes of cumulative RF energy delivery time per center despite similar patients and targets (indicating the current lack of standardized ablation techniques). (For more on the AFACART study, see AF Symposium 2015: AFACART Clinical Trial.)

Persistent A-Fib Case: In the case of a 48-year-old female in Persistent A-Fib for four months, four target areas were identified: the inferior Left Atrium (LA), the LA Septum, the anterior of the LPV (Left Pulmonary Vein) to the LAA, and the posterior area of the RPV (Right Pulmonary Vein). (They divide the left and right atria into seven general physical areas.) A-Fib continued after these driver areas were ablated. On re-mapping, the septum area was found to be still active. After 2 more minutes of RF delivery to that septum area, A-Fib terminated into normal sinus rhythm.

Ablation Failure From Thicker Atrial Tissue?

Dr. Haissaguerre pointed out that ablation failure happens particularly in the right and left atrial appendages because of thicker atrial tissue. He showed a slide where he ablated one driver area, then six months later ECGI showed a new driver region at the LAA ridge.

Right Atrium Drivers Reduced After Left Atrium Ablation

Next, he showed slides where the ECGI mapping system initially showed driver activity in the Right Atrium (RA). But after Left Atrium (LA) ablation, this driver activity was greatly reduced. He suggested that RA drivers might mirror or be a projection of LA drivers.

Right Atrium drivers might mirror or be a projection of Left Atrium drivers.

(This is a new research finding that may be very important and may change the way the right atrium is ablated in persistent A-Fib cases.)

ECGI After Prior Extensive PVIs

Dr. Haissaguerre showed slides of patients who had had two or three prior PVIs. ECGI clearly showed where there were still driver regions. Each patient’s persistent A-Fib was terminated into normal sinus rhythm.

Mapping of Atrial Tachycardias (ATs)

The ECGI system can also map Atrial Tachycardias (AT). Dr. Haissaguerre found that half the ATs found were focal ATs, “mostly localized reentry”; 68% were from driver regions previously ablated; 32% were from new sites.

The other half of the ATs were “Macroreentries” and required linear ablations to terminate.

Limitations of ECGI NonInvasive Driver Mapping

According to Dr. Haissaguerre:

• Body filtering (ECGI) may miss small local AF Signals, while showing the main propagating waves in a panoramic scope
• Extensive ablation may affect egm (electrogram) quality and analysis
• Besides ‘drivers’, other mechanisms of AF perpetuation may coexist, particularly in longer lasting (>1 year) AF

Dr. Haissaguerre’s Conclusions

• Remapping can confirm elimination or persistence of drivers or show new drivers (requiring further ablation)
• This dynamic information will probably increase the rate of AF termination
• Further improvement expected with rapid mapping of Atrial Tachycardias

What Patients Need to Know

The ECGI/ECVUE Cardio Insight body surface mapping seems like a major improvement and development, particularly for patients in persistent A-Fib, usually the hardest to cure.

ECGI is probably the most significant, game changing improvement in the treatment of A-Fib (along with Contact Force sensing catheters).

This ECGI system is being carefully developed in eight centers in Europe (AFACART clinical trial). It was recently purchased by Medtronic and is headquarted in Dublin, Ireland.

(No one at the Medtronic booth at the AF Symposium exhibit hall could tell me when the ECGI system will be available for examination and use in the US and worldwide. I’ll update this report when I know.)

Re-Mapping a Major Improvement in ECGI: We’re grateful to Dr. Haissaguerre and the Bordeaux group for developing the technique of re-mapping during an ablation. It’s certainly a major improvement in what was already a very good mapping and ablation system.

Mapping and Ablating Atrial Tachycardias (ATs): From a patient’s perspective, it’s great to know that ECGI can be used to identify and ablate atrial tachycardias (fast heart rates).

A-Fib termination can result in normal sinus or ATs which are a form of sinus rhythm. For most people, ATs are certainly better than being in A-Fib. But they can be annoying and disruptive. It’s good to know they can be mapped and ablated just like A-Fib signals.

ECGI May Miss Small Local ATs and A-Fib Signals: ECGI isn’t perfected yet. Dr. Haissaguerre showed that many of the local ATs found came from driver regions previously ablated.

DR. MICHEL HAÏSSAGUERRE

 CHU Hopitaux de Bordeaux logoDr. (Prof.) Michel HaïssaguerreCentral Hospital, Bordeaux, France, and his colleagues invented pulmonary vein catheter ablation for A-Fib (PVA/I). The Bordeaux Group is considered one of the top A-Fib centers in the world and noted for their cutting edge research in the treatment of Atrial Fibrillation. Interesting fact: I (Steve Ryan) was their first US patient in 1998.

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2016 AF Symposium: In-depth Reports for Patients by Steve S. Ryan, PhD

Steve Ryan at 2016 AF Symposium

Steve Ryan at 2016 AF Symposium

AF Symposium 2016

My Summary Reports Written for A-Fib Patients

by Steve S. Ryan, PhD

Each year I attend the AF Symposium to get a thorough and practical view of the state of the art in the treatment of A-Fib. My goal is to offer patients the most up-to-date A-Fib research and developments that may impact their treatment choices.

Note: My most recent reports are listed first.

REPORT TITLE PRESENTER (S) DATE POSTED
7. Thickening of Left Atrium and Amount of Fibrosis Predicts Outcome of A-Fib Ablation Dr. Nassir F. Marrouche, University of Utah, Salt Lake City, UT Feb. 22, 2016
6. Hot Topic—Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib Dr. David Wilber of Loyola University Medical Center, Chicago, IL Feb. 14, 2016
5. Two Challenging, Difficult Catheter Ablation Cases with LAA Closure Dr. David Keane, St. Vincent’s University Hospital, Dublin, Ireland (Moderator); Drs. Vivek Reddy and Migel Valderrabano Feb. 12, 2016
4. Predictors of Unsuccessful Ablations: It’s All About Remodeling Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France Feb. 11, 2016
3. Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France  Feb. 10, 2016
2. 2016 AF Symposium: Six Live Catheter Ablations—Watching the Experts Dr. Moussa Mansour and Dr. Jeremy Ruskin, co-moderaters, Mass. General Hospital, Boston,MA  Feb. 9, 2016
1. 2016 AF Symposium Overview by Steve S. Ryan, PhD – – – Feb 8, 2016

“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

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Steve’s 2016 AF Symposium Reports: For the Most Recent Advances in A-Fib Treatments

Want the latest on emerging treatments for Atrial Fibrillation? The most recent research findings? From the best in the world? Me too! That’s why I attend the annual AF Symposium held each January in Orlando, FL.

Steve Ryan at the 2016 AF Symposium, Jan 14-16.

Steve Ryan at the 2016 AF Symposium, Jan 14-16.

The 2016 AF Symposium brought together the world’s leading cardiologists, medical researchers and scientists to share the most recent advances in the field. It is one of the most important medical conferences on Atrial Fibrillation in the world.

What this Means to You

My aim is to pare down the significant research findings to the essentials and ‘translate’ them into plain language (as much as possible) for A-Fib patients and their families. I then add my own comments and insights.  

You won’t find this information in this format anywhere else.

My Overview and First Reports

Begin with my Overview. Find out what was the Most Discussed topic! And the Most Controversial topic! I also give you a few highlights and a list of conference topics. Look for my first summary reports starting later this week.

Start here: go to my AF Symposium Overview.

2016 AF Symposium Overview

Steve Ryan at the 2016 AF Symposium

Steve Ryan at the 2016 AF Symposium

Mechanisms and New Directions in Therapy, January 14-16, 2016, Orlando, FL

by Steve S. Ryan, PhD, February 9, 2016

The annual AF Symposium is an intensive and highly focused three-day scientific forum which brings together the world’s leading medical scientists, researchers and cardiologists/electrophysiologists to share the most recent advances in the treatment of atrial fibrillation.

Why I Attend

Each year I attend the AF Symposium to learn and ‘absorb’ the presentations and research findings. Attending the sessions gives me a thorough and practical view of the current state of the art in the field of A-Fib. I then sort through this newly acquired knowledge and understanding for what’s relevant to patients and their families. Over the next months, I will try to post 20–35 reports on my website, A-Fib.com.

The Venue: Hyatt Regency Orlando

The 2016 AF Symposium was held at the 4-star Hyatt Regency Orlando hotel in Orlando, Florida.

The scientific session presentations were held in the huge Windermere Ballroom equipped with five floor-to-ceiling display screens with additional floor monitors and perfect audio from any seat. the ballroom’s temperature was comfortable (and not too cold/hot like last year.)

5-floor-to-ceiling video monitors at the Hyatt Regency Orlando: 2016 AF Symposium

5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

An improvement from last year was the separate Exhibition area just down the hall. (Last year the sound from the exhibit area intruded into and disrupted the scientific sessions’ presentations.) Everything ran smoothly (except the initial audio of the first live case presentation.) and included satisfying lunches and break refreshments.

With the room rates starting at $129/night and parking at $18.00/day, I stayed at the Motel 6 nearby ($30.00 per night with an AARP card discount) and happily was able to park nearby for free.

News & Views from the 2016 AF Symposium

The dominant mood or feeling of the 21st AF Symposium was a sense of or awareness of ‘dynamic, incremental, focused change’ coupled with heated controversy over rotors.

Each day started at 7:00 AM and finished around 6 PM (Saturday adjourned mid-afternoon to enable catching evening flights home.)

Short Sessions

There were 55 different short presentations (10 or 15 minutes) by 56 A-Fib experts and researchers from around the world. Each talk was usually followed by a Q&A with audience members.

Every seat was equipped with an interactive audience response device so each attendee could enter their answer to any multiple choice question posed by presenters. The results were then flashed up on the screen for further discussion.

Lightning Rounds

Some sessions were followed by “Lightning Rounds” on a particular problem or question. Panelists and the audience could answer the question or share how their facility handles that particular problem. For example, “Which patients should have their Left Atrial Appendage closed off?” or “How do you protect the esophagus during an ablation?”

Live Ablation Cases via Streaming Video: Worth the Price of Admission

Live Streaming Video from AF Symposium at A-Fib.comThere were six live video presentations (via internet streaming video) of ablations from centers around the world:

• Seoul, S. Korea
• Munich, Germany
• Bordeaux, France
• Austin, Texas
• Philadelphia, Pennsylvania
• Boston, Massachusetts

As usual, these live case presentations were worth the price of admission.

The presentation of the live case from Korea had to be postponed for a while until they could work out a technical problem with the audio. (Having worked in broadcast television for 16 years, I know you can have a perfect test run but have something go wrong during the live event.)

Topics Overview

To give you a sense of the scope of subjects covered at this AF Symposium, each of the following eleven session topics had 6-9 different talks relating to that subject:

• New Insights into the Pathophysiology, Genetics and Epidemiology of AF— The Science and Mechanisms of A-Fib
• Frontiers in Atrial Fibrillation—Management of A-Fib Patients
• Challenging Cases in AF Management: Anticoagulant Drugs, Anticoagulation, and Clinical Decision Making
• Clinical Trials and Regulatory Issues in AF Ablation—Featuring Presentations by the FDA
• Left Atrial Appendage Closure: Devices, Techniques and Clinical Outcomes—Probably the Second Most Important Topic of this AF Symposium
• Case Presentations: Catheter Ablation for Atrial Fibrillation—Six Live Cases
• Optimizing the Safety and Effectiveness of Pulmonary Vein Isolation Part I and Part II
• Anticoagulation Part I and II: A New Era in Pharmacological Stroke Prevention in Atrial Fibrillation
• Advances in Catheter Ablation for Persistent AF: Mechanisms, New Tools and Outcomes
• Rotors and Other Mechanisms in Persistent AF: Concepts and Controversies—The Most Hotly Discussed Topic in this AF Symposium
• Challenging Cases in Catheter Ablation and LAA Closure for AF

The Most Discussed

The most discussed and argued about topic was non-PV triggers/drivers/rotors.

The most important and historically significant statement made at this AF Symposium was by Dr. Vivek Reddy of Mount Sinai Hospital in New York City:

“The mapping and ablation of Non-PV Triggers is the next step in the evolution of catheter ablation of atrial fibrillation.”

The Most Controversial

The most important and controversial session was Saturday morning’s “Rotors and Other Mechanisms in Persistent AF: Concepts and Controversies.”

 The panel discussions about rotors became very heated.

It was somewhat disconcerting to hear some cardiologists argue that rotors don’t exist. Dr. Waldo: “I don’t find any rotors.” Dr. Allessie: “If you see rotors, they are wrong.”

Yet during the three days of the Symposium, rotors were the subject of many presentations. The new mapping systems like FIRM and ECGI/ECVUE map, identify and ablate rotors. I kept asking myself how can they say that rotors don’t exist?

Steve at 21st Annual AF Symposium in Orlando FL

Steve at 21st Annual AF Symposium in Orlando FL

The panel discussions about rotors became very heated. A possible reconciliation occurred when Dr. Allessie stated that rotors and breakthroughs can coexist. One drives the other.

Dr. Karl-Heinz Kuck added to the confusion and controversy when he showed a different but similar type of ECGI vest that he uses to map rotors. He doesn’t get the same results as the Bordeaux group and Dr. Haissaguerre.1

As Dr. Jose Jalife summed up:

“For the first time in 20 years, we are talking about mechanisms rather than being ‘anatomicalists’.”

Dynamic, Incremental, Focused Change

Though this is a very subjective non-scientific view, to me the dominant mood or feeling of this year’s AF Symposium was a sense of or awareness of ‘dynamic, incremental, focused change’ coupled with heated controversy over rotors.

The Next AF Symposium: The 2017 AF Symposium will also be at the Hyatt Regency Orlando, January 12-14, 2017.

My Summary Reports

Look for my first summary reports starting later this week.

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Footnote Citations    (↵ returns to text)

  1. I couldn’t tell if Dr. Kuck was speaking tongue-in-cheek or was really serious when he added: “I burn and nothing happens. I don’t understand how to ablate.” Then he said he was stopping ablations until he knew how. (No one in the room knew if he was kidding or not.)

The 2016 International AF Symposium: Research You Can Use

Sunday I returned home from four days in Orlando, FL, and the 21st Annual AF Symposium.

Why I Attend the International AF Symposium

The AF Symposium brings together the world’s leading cardiologists, medical researchers and scientists who share the most recent advances in the field. It is one of the most important medical conferences on Atrial Fibrillation in the world.

AF Symposium SSR 400 pix wide at 300 res

Steve Ryan at the 2016 AF Symposium

Each year I attend to listen, learn and ‘absorb’ the presentations and research findings. (I take loads of notes.) The conference gives me a thorough and practical view of the state of the art in the treatment of Atrial Fibrillation (A-Fib).

After each presentation, I ask myself: “What does this mean to A-Fib patients?” “How might this impact the treatment decision patients are making now and in the future?” “What will my A-Fib.com readers what to know about?”

What This Means to You

My aim is to pare down the significant research findings to the essentials and ‘translate’ them into plain language (as much as possible) for A-Fib patients and their families. I then add my own comments and insights.

“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, Mass. General Hospital & Harvard Medical School

On the plane ride home, I start a summary of the conference and an overview of the most popular topics or issues.

In the months following the Symposium, I write and post three or four reports each month usually ending up with about 20–30 articles. (Why does it take so long? I send each summary to the presenter inviting their feedback; so it takes some time to get each article written, reviewed, and then posted.)

My Reports are Coming Soon

My reports are written just for A-Fib patients and their families. You won’t find this information in this format anywhere else. (BTW: physicians, cardiologists and electrophysiologists read my reports, too.)

I will post my Symposium Overview soon followed by my first eight reports.

To learn more: If you want to review my 2015 AF Symposium reports, see 2015 AF Symposium Reports by Steve S. Ryan, PhD; For more about the AF Symposium see: What is the Annual ‘AF Symposium’ and Why it’s Important to Patients

Critical Analysis of the FIRM Mapping System

Loma Linda University in Loma Linda, CA,

Dr. Ravi Mandapati

AF Symposium 2015

Critical Analysis of the FIRM Mapping System

By Steve s. Ryan, PhD

There was probably no more heated discussion at the 2015 AF Symposium than about the FIRM mapping system.

Dr. Ravi Mandapati of Loma Linda University in Loma Linda, CA, gave a presentation entitled “Lack of Evidence of Stable Rotors with Multipolar Mapping of Persistent AF.”

In his presentation Dr. Mandapati compared data from his study of FIRM ablations performed at UCLA Medical Center to the CONFIRM clinical trial data published by Dr. Sanjiv Narayan, one of the inventors of the FIRM mapping system.

Background: The FIRM mapping system uses a multipolar basket catheter (FIRMap™), a novel panoramic contact-mapping tool by Topera. FIRM stands for Focal Impulse and Rotor Modulation.

Dr. Mandapati echoed other 2015 AF Symposium speakers in stating that “the (FIRM) multipolar basket catheter provides inadequate coverage of the left atrium with half the surface area unsampled.” He showed slides where only 54% of the left atrium surface area was mapped by the FIRM system.

“The (FIRM) multipolar basket catheter provides inadequate coverage of the left atrium, with half the surface area unsampled.”

In an editorial in the Journal of Innovations in Cardiac Rhythm Management, Dr. John Day (Intermountain Health, Utah), echoed Dr. Mandapati’s concerns about the mapping basket catheter. The greatest limitation of rotor mapping is from the archaic Constellation basket mapping catheter developed nearly 20 years ago with few changes over the years.

Dr. Day wrote, “This contact mapping basket often does not fit the very enlarged left atria we typically see with ablation of the more persistent forms of atrial fibrillation.” Also, the base of the basket catheter doesn’t have any electrodes. Dr. Day added, “Thus, the left atrial septum is a blind spot with this catheter.”

[But Topera is working on developing its own line of mapping basket catheters to address these shortcomings.]

Sustained Rotors Not Found by Other Research

Dr. Mandapati discussed one of the early articles about CONFIRM trial results by FIRM inventor, Dr. Sanjiv Narayan, who observed “sustained sources in 47/49 patients, in the form of electrical rotors (N=57) and focal beats (N=11).”

Dr. Mandapati then described his own research. He and his colleagues looked at FIRM-guided ablation procedures performed at the UCLA Medical Center (n=24). (Dr. Narayan actually performed 11 of those cases while he was at UCLA and assisted in others.) A quantitative analysis was performed of EGMs (electrocardiograms) of FIRM rotors and non-rotor sites.

Dr. Mandapati’s own research looked at FIRM-guided ablation procedures performed at the UCLA Medical Center.

In contrast to the CONFIRM trial results, Dr. Mandapati’s analysis of UCLA FIRM results failed to demonstrate similar stable reentrant rotors.

Rotor Sites Don’t Show Distinct Electrophysiological Characteristics

Dr. Mandapati’s UCLA study showed that FIRM-identified rotor sites didn’t exhibit features distinguishing them from other atrial sites. He showed slides of disorganized activation patterns at rotor sites.

He used Frequency Domain and Shannon Entropy Analysis to show how rotors don’t appear where one would expect them to be found.

[Shannon Entropy is one of the most important metrics in information theory. It measures the uncertainty associated with a random variable, i.e. the expected value of the information in the message (in classical informatics it is measured in bits). The “entropy” of the message is its amount of uncertainty; it increases when the message is closer to random, and decreases when it is less than random.]

Quantitative Analysis of FIRM Rotor Sites and Ablation Results

Dr. Mandapati and his colleagues did a quantitative analysis of FIRM rotor sites and ablation results. They found a success rate of 50% (12/24) and the following:

― AF termination: 1/24 [how many patients were returned to sinus rhythm without resorting to shocks or drugs]

― AF organization: 3/24 [how many converted to an organized arrhythmia such as Flutter as compared to a more disorganized arrhythmia such as A-Fib.]

― AFCL (A-Fib cycle length) slowing of at least 10%: 8/24 [how many patients’ A-Fib frequency was slowed; a step in returning a patient to sinus rhythm.]

In addition, after approximately 500 days of follow-up, they found the following intermediate outcomes:

• Survival free from AF: 46%
• Survival free from Atrial Tachycardia (ATA): 38%
• Survival free from ATA and off Antiarrhythmic Drugs (AAD): 29%

In contrast, Dr. Sanjiv Narayan’s CONFIRM studies found:

• Survival free from AF: 82%
• Survival free from ATA: 71%
• Survival free from ATA and off AAD: 79%

Researchers found the following FIRM long-term clinical outcomes:

• Long term follow up results (from two centers):
– Single procedure freedom from AF: 37%
– Single procedure freedom from ATA: 30%
– Single procedure freedom from ATA off ADD: 21%
• No patient who underwent FIRM-guided ablation alone (n=5) was free from ATA off AADs.

Dr. Mandapati’s Conclusions:

1. The FIRM multipolar basket catheter provides inadequate coverage of the left atrium, with half the surface area unsampled, and decipherable atrial electrograms from only 48% of electrodes

2. FIRM identified rotor sites do not exhibit distinctive electrophysiological characteristics with regard to dominant frequency or Shannon entropy

The FIRM multipolar basket catheter provides inadequate coverage of the left atrium.

3. Rotational activation (>1 rotation) on electroanatomic mapping was not observed at FIRM-identified rotor sites

4. Ablation of rotor sites, even when accompanied by PVI, did not result in AF termination in the majority (20/24, 83%) of patients.

5. Long term follow up results (2 centers) were disappointing. Single procedure freedom from AF, all ATA and all ATA off AAD were 37%, 30% and 21%.

And he stated, “Rotor ablation should be validated scientifically to get a mechanistic understanding and subsequently should be assessed in prospective randomized trials.”

Further Research Questions

Dr. Mandapati raised the following questions that need to be addressed in further research:

1. If a rotor is deemed to be stable (mother rotor), what are the characteristics, the number of rotations, stability, etc.?
2. What percentage of the atrium should be mapped to deem a rotor the driver/mother?
3. Are these rotors functional or structural?

What Patients Need to Know

Up to this point in time, everyone seemed to be jumping on the FIRM/Topera ‘bandwagon’ with very little critical analysis or understanding of how it worked.

We are very indebted to Dr. Mandapati and his colleagues at UCLA Medical Center for what is probably the first in-depth critical analysis of the FIRM mapping system.

Be Skeptical of the FIRM Mapping System

As patients, we should now be skeptical of the FIRM system:

• It doesn’t map nearly ½ of the left atrium
• The FIRM mapping algorithms finds stable rotors that other research finds are not stable, and electrophysical characteristics that other research doesn’t confirm
• Results of ablating FIRM-identified rotor sites are relatively poor. (This is what should most concern us as patients.)

Patients seeking an ablation should be cautious of the FIRM system

Dr. Mandapati’s critical analysis of FIRM is co-authored by several leading Electrophysiologists (EPs) at the UCLA Medical Center (where both Dr. Mandapati and Dr. Narayan worked when this study was done).

The Bottom Line

At this point, as an A-Fib patient, you may ask: “Should I now stay away from doctors or centers using the FIRM system?”

My answer: No. Even though the FIRM-guided ablation system may have problems and inherent limitations, it may still work well for you and be better than regular mapping.

The FIRM-guided ablation procedure has great potential, but currently offers mixed or uneven results. A competing system, ECGI (Non-Invasive Electrocardiographic Imaging), has better clinical trial results but is only available in Europe at this time. (For more on ECGI, see my AF Symposium article, How ECGI [Non-Invasive Electrocardiographic Imaging] Works)

If choosing an ablation using the FIRM mapping system, discuss these limitations with your doctor before your ablation.

[FYI: The FIRM technology by Topera, developed by Dr. Sanjiv Narayan and others, was sold to Abbott Laboratories in December 2014 for $250 million; Dr. Narayan received around $10 million dollars from the sale.]

Additional Research Studies Support Similar Conclusions

Posted January 4, 2016: A recent three-center study (Texas Cardiac Arrhythmia Institute-Austin, TX, Heart Center Bad Neustadt-Germany, Baptist Health, Lexington, KY) using FIRM-guided only ablation in patients with persistent or long term persistent A-Fib also found poor results.
“Targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization or slowing (≥10%) during the procedure.”
Posted January 9, 2016 In a follow-up article by Dr. Gianni and colleagues, rotors-only ablation was performed in 65% of persistent (91%) and long term persistent (9%) patients. In the other 35%, rotors-only ablation was performed after conventional ablation.
The success rates were respectively 25% vs. 53%.

The authors again found that FIRM-guided ablation was not effective in obtaining A-Fib slowing/organization/termination during the procedure, “and in preventing mid-term AT/AF recurrences.”

References for this article
Benharash P. et al. Quantitative Analysis of Localized Sources Identified By Focal Impulse And Rotor Modulation Mapping in Atrial Fibrillation 2015 (submitted-in-review) URL: http://www.ncbi.nlm.nih.gov/pubmed/25873718. doi: 10.1161/CIRCEP.115.002721

Narayan, SM et al. Clinical Mapping Approach to Diagnose Electrical Rotors and Focal Impulse Sources for Human Atrial Fibrillation. J Cardiovasc Electrophysiol, Vol 25. Pp. 447-454. May 2013. URL: http://www.ncbi.nlm.nih.gov/pubmed/22537106. doi: 10.1111/j.1540-8167.2012.02332.

Share, M. et al. Clinical Outcomes of Focal Impulse and Rotor Modulation (FIRM) for Treatment of Atrial Fibrillation: Single Center Experience. AH 2014. URL: http://circ.ahajournals.org/content/130/Suppl_2/A14906.

Lee G et al. Epicardial wave mapping in human long-lasting persistent atrial Fibrillation: transient rotational circuits, complex wavefronts, and disorganized activity. Circulation 2000: 101-124. URL: http://www.ncbi.nlm.nih.gov/pubmed/23935092. doi: 10.1093/eurheartj/eht267.

Day, John. Letter from the Editor In Chief. The Journal of Innovation in Cardiac Rhythm Management, February 2013, 4 (2013), A5-A6. URL: http://www.innovationsincrm.com/cardiac-rhythm-management/2013/february/401-letter-from-the-editor-in-chief-february-2013

Abbott Topera Solution. URL: http://www.abbottep.com/medical-device-products/topera-3d-rotor-mapping-system/topera-technology/

Gianni, C. et al. Acute and early outcomes of FIRM-guided rotors-only ablation in patients with non-paroxysmal atrial fibrillation. Heart Rhythm. December 17, 2015. http://www.heartrhythmjournal.com/article/S1547-5271(15)01554-4/abstract

Gianni, C. et al. Abstract 16017: Mid-term Outcomes in Persistent and Long-standing Persistent Atrial Fibrillation Patients Undergoing Rotor Ablation. Circulation. 2015;132:A16017. http://circ.ahajournals.org/content/132/Suppl_3/A16017.short?related-urls=yes&legid=circulationaha;132/Suppl_3/A16017

Report: FIRM Mapping System—Should Ablation Patients Avoid It?

The FIRM mapping system was a hot topic at the last annual AF Symposium. In his presentation Dr. Ravi Mandapati compared data from his study of FIRM ablations performed at UCLA Medical Center to the CONFIRM clinical trial data published by Dr. Sanjiv Narayan, one of the inventors of the FIRM mapping system.

Topera-FIRMap catheter - three sizes

Topera-FIRMap catheter (three sizes)

Up to this point in time, everyone seemed to be jumping on the FIRM/Topera ‘bandwagon’ with very little critical analysis or understanding of how it worked.

As patients, we should now be skeptical of the FIRM system:

• It doesn’t map nearly ½ of the left atrium
• The FIRM mapping algorithms finds stable rotors that other research finds are not stable, and electrophysical characteristics that other research doesn’t confirm
• Results of ablating FIRM-identified rotor sites are relatively poor. (This is what should most concern us as patients.)

So, as an A-Fib patient, you may ask: “Should I now stay away from doctors or centers using the FIRM system?” Read my answer and my full 2015 AF Symposium report at Critical Analysis of the FIRM Mapping System.

For more background also see my 2014 AF Symposium report: ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping.

AF Symposium 2015: Clues to Finding Drivers When Ablating for Persistent A-Fib

Pierre Jais MD

Pierre Jais MD

In my new report, Dr. Pierre Jais of the French Bordeaux/LIRYC group describes a research study of ablations performed on 50 patients with persistent A-Fib. He shares the insights he learned using the CardioInsight mapping system (ECGI) to map and ablate A-Fib signal drivers.

First, a little background. During an ablation procedure, A-Fib signals are mapped and lesions made to eliminate the signal drivers. After this initial effort, it is not uncommon for some arrhythmias signals to continue. So, another round of time-consuming mapping, analysis and diagnosis is needed.

Dr. Jais describes how he used the research data from the ECGI and learned how to anticipate the probable location of these additional A-Fib signals.

This is a very important clue for doctors and patients. It helps doctors spend less time mapping and ablating these additional sources of A-Fib signals. The benefit to the patient is a shorter ablation procedure time and fewer lesions (burns) to eliminate the A-Fib signals.

To learn more, see my 2015 AF Symposium report, see Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions.

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

AF Symposium 2015

Sébastien Knecht PMD PhD

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

By Steve s. Ryan, PhD, July 2015

Pr. Sebastian Knecht from CHU Brugmann, Brussels, (now AZ Sint Jan, Brugge), Belgium gave a presentation entitled “AFACART Trial—Design and Preliminary Results.” (AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI).

Introduction

In preparation for their ablation the patient dons the ECGI vest-like device. The data generated creates an image of the heart and pinpoints sites (“drivers”) producing A-Fib signals. This 3-D computer model of the patient’s heart is used during the ablation procedure.

AFACART Clinical Trial Design and Participants

The AFACART trial is a European multicenter, feasibility, non-randomized study using “Panoramic Electrographic Non-Invasive Mapping”, specifically the CardioInsight—ECVUE System, for ablation of persistent A-Fib. 

AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI

Ablation patients are to be followed for 12 months. The effectiveness of Panoramic Electrographic Non-Invasive Mapping is to be compared to conventional mapping and ablation procedures.

Eight European centers in France, Belgium and Germany are participating in this clinical trial. None of these centers had any practical experience with this system before this study.

Ablation Steps One to Three

In an important change to standard ablation procedures, the first step in the ECGI/ECVUE ablation process is ablation of A-Fib drivers (rotors and foci).  (This is in comparison to the step-wise approach that begins with ablation of the pulmonary vein openings.)

If A-Fib doesn’t terminate to sinus rhythm or stable atrial tachycardia isn’t achieved (> 5 min), then a standard PVI is performed.

This is followed by linear lesions. And finally by Electrocardioversion.

AFACART Trial Preliminary Results

• Step One (driver ablation only): 64% of the persistent A-Fib patients had their A-Fib terminated.
• Step Two (driver and PVI ablation): 66% termination
• Step Three (driver, PVI, and LA linear lesions) 73% termination

For our technical readers, Dr. Knecht defined ‘drivers’ as “local reentrant circuits (> 1.5 rotations) or focal breakthroughs (>2) that appear at the same spatial location per window.”

In 94% of patients, driver ablation had a significant impact on the A-Fib termination process. A-Fib cycle length was prolonged in all persistent patients except for 6%. Even patients who were not terminated (27%) had their A-Fib cycle length prolonged by driver ablation.

After 12 months, 72% of patients were A-Fib free and no longer taking antiarrhythmic meds (AADs). 31% had Atrial Tachycardia recurrence, but many had a second ablation.

Overall 83% were A-Fib free, 17% had Atrial Tachycardias and only 9% were still in A-Fib.

Ablation procedure time averaged only 44.7 minutes. As the number of driver regions increased, the ablation success rate decreased. 66% of drivers were in the Left Atrium, 34% in the right. 70% of termination sites were in the left atrium, 30% in the right.

Driver Sites and CFAEs

• In these persistent A-Fib patients, 50% of both atria had CFAEs.
• Most (but not all) driver sites contained CFAEs.
• Successful driver ablation only ablated 19% of both atria (this is a major improvement and resulted in much less ablation damage to the heart compared to trying to ablate all CFAE areas).

Dr. Knecht stated that “use of the ECVUE system seems to result in a more specific selection of CFAEs leading to a more targeted ablation strategy.”

Dr. Knecht’s Conclusions

Ablation of A-Fib drivers is associated with a high rate of A-Fib termination.

• Drivers are distributed in both atria (2/3 LA and 1/3 RA).
• Results are reproducible among centers without prior practical experience with the system.
• Preliminary chronic results are very promising.

Editor’s Comments:
Driver Ablation More Important Than PVI in Persistent A-Fib: ECGI is changing the way ablations are done and our understanding of A-Fib. In persistent A-Fib, the mapping and ablation of drivers is more important and is done before a PVI ablation. While driver ablation had a 64% success rate, doing a standard PVI after driver ablation only improved results by 2%.
ECGI/ECVUE Major Improvement in Ablation Success Rate: An 83% success rate after 12 months following ablations for tachycardias, is a major improvement and source of hope for persistent A-Fib patients. These results were even better when one considers that only 9% were still in A-Fib.
ECGI/ECVUE Results in Much Fewer Ablation Burns: Previous protocols for ablating persistent A-Fib usually involved mapping and ablating CFAEs. But CFAEs in persistent A-Fib patients can cover 50% of the atria surfaces which often necessitated a lot of burns and debulking.
Too many ablation burns could result in the development of fibrosis (dead heart tissue where the ablation catheter produced burns and scarring) and a stiffening of the atria with loss of pumping ability. ECGI/ECVUE only requires ablating 19% of the CFAE areas resulting in much less lasting damage to heart tissue.
Driver Ablation Prolongs A-Fib Cycle Length: Driver ablation had a major effect on the A-Fib termination process. A-Fib cycle length was prolonged in all but 6% of the persistent A-Fib patients. This is perhaps a first step in improving outcomes for persistent A-Fib patients.
Reproducibility: The most important finding of Dr. Knecht’s report is that ECGI/ECVUE works in other centers without doctors (operators) having to undergo extensive training.
These preliminary results from this multi-center clinical trial are quite impressive for the treatment of patients with persistent A-Fib. Hopefully it won’t be long before the ECGI/ECVUE system is available in more countries. (ECGI was invented at Washington Un. in St. Louis, MO and is available there on a limited basis.)

To learn more about ECGI, see Non-Invasive Electrocardiographic Imaging (ECGI): Presentation Summary and Comments from the 2013 AF Symposium. You may want to read this report in conjunction with Dr. Haissaguerre’s 2015 AF Symposium presentation The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques.

References for this article
Non Invasive Mapping Before Ablation for Atrial Fibrillation: THE AFACART STUDY. ClinicalTrials.gov Identifier: NCT02113761. Sponsor: Brugmann University Hospital. Responsible Party: Pr Sébastien Knecht, PMD PhD, Brugmann University Hospital. URL: https://clinicaltrials.gov/ct2/show/NCT02113761

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Last updated: Friday, January 1, 2016

Persistent A-Fib: ECGI Insights to Finding Additional Drivers by Dr Jais

AF Symposium 2015

Pierre Jais MD

Pierre Jais MD

Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions

By Steve s. Ryan, PhD, July 2015

Dr. Pierre Jais of the French Bordeaux/LIRYC group gave a presentation on “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”

He described a study of the ablation of 50 persistent A-Fib patients using ECGI to map and ablate A-Fib signal drivers.

A-Fib was terminated in 79% of patients, with 10% returned to sinus rhythm and the remaining 69% in tachycardias (but with no A-Fib).

For those still in arrhythmia, ECGI was used to map, analyze and diagnose the locations of the arrhythmias signals, and additional ablation lesions were performed. Identified were 25 macro-reentry circuits and 14 focal/localized-reentry circuits.

The reentry circuits found by ECGI were:

• common atrial flutter in 14 patients
• perimitral flutter in 9 patients
• roof dependent flutter in 2 patients

Dr. Jais showed many slides and videos of how ECGI mapped and analyzed where these arrhythmias were coming from and how they were ablated.

Dr. Jais’ Conclusions

Dr. Jais stated that the study data revealed, “the focal/localized-reentry were adjacent to drivers at 0.9cm from the core of driver with low voltage (0.5 mV)”.

To clarify, this means that the drivers of the remaining arrhythmias were located very close (adjacent) to the drivers previously mapped by ECGI.

Therefore, when ECGI locates an area of rotors and drivers, it is highly likely this is where the source of additional arrhythmias will most likely be found. This insight reduces or eliminates the need (and time) to search other areas of the heart thereby shortening procedure length and decreasing the number of lesions needed.

Editor’s Comments:
ECGI mapping and ablating is changing our understanding of and our techniques for ablating persistent A-Fib. If a patient has continued arrhythmias after the initial ablation, ECGI often can re-map and identify where the remaining arrhythmias are coming from, usually very near previously identified driver locations. This is a valuable insight for doctors doing ablations.
For patients, it may mean a shorter procedure time with fewer burns needed to eliminate the sources of A-Fib signals.

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Last updated: Thursday, August 6, 2015

AF Symposium 2015: Going Beyond PVI With ECGI Mapping and Ablation Techniques

Dr Michele Haïssaguerre, The French Bordeaux group

Dr Michele Haïssaguerre, The French Bordeaux group

ECGI is changing everything. Instead of potentials and CFAEs, EPs will focus on ablating drivers (rotors and foci). Prof. Michel Haïssaguerre of the French Bordeaux group/LIRYC gave a presentation on the changing world of catheter ablation using Non-Invasive Electrocardiographic Imaging, or ECGI (from CardioInsight), a radically new and innovative mapping and ablation system.

The system automatically detects rotors and foci and computes them into a “Cumulative Map” or movie. These driver regions are ranked, based on statistical prevalence. They are displayed in statistical density maps which define the ablation road map.

Ablation using ECGI results in a dramatic decrease of RF burns needed to produce A-Fib ‘termination’.

Dr. Haïssaguerre showed slides where he ablated driver regions which then transformed rapid complex A-Fib signals into slower organized signals.

Read more about Dr. Haïssaguerre’s experiences with ECGI, driver regions and long-lasting persistent A-Fib.

AF Symposium 2015: A-Fib Doubles Silent Stroke Risk and is Associated with Dementia

John D Day MD

John D Day MD

Dr. John Day of the Intermountain Heart Institute, discussed how A-Fib doubles the risk of having a silent stroke. Many studies have shown that A-Fib is independently associated with dementia. “AF is associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke.”

In one study of 11,723 patients, those with arrhythmia were 4½ times more at risk of developing dementia.

Dr. Day described four possible mechanisms that may lead to A-Fib dementia:

1. Macro/Micro Thromboembolism (strokes)
2. Cerebral Bleeds
3. Weakened Cerebral Blood Flow
4. Systemic Inflammation

For more details about A-Fib and dementia, read my complete summary of Dr. John Day’s 2015 AF Symposium report.

AF Symposium 2015: Silent Brain Lesions Before Ablation of Greater Concern

Jose Kautzner MD

Jose Kautzner MD

Dr. Josef Kautzner’s presentation demonstrated that living with “AF is more dangerous than its ablation” because of the risks of cerebral lesions and cognitive impairment. Small cerebral lesions don’t seem to cause symptoms, but obviously doctors want to avoid creating any kind of lesions on the brain if at all possible.

In MRI tests, a high proportion of A-Fib patients before ablation had silent cerebral infarctions or lesions (60%-80%). But the problem is that similar lesions were detected by MRI even in patients without documented A-Fib.

Therefore, we still do not know how much A-Fib contributes to the development of such lesions. On the other hand, their presence may explain (at least in part) the association between A-Fib and dementia.

Read my AF Symposium summary on how silent brain lesions develop, and proposed strategies to minimize the risk of silent lesions.

AF Symposium 2015: What You Need to Know About AHA/ACC/HRS Treatment Guideline Changes

Dr. Hugh Calkins

Dr. Hugh Calkins

Dr. Hugh Calkins from Johns Hopkins University discussed the new AHA/ACC/HRS Guidelines for the Treatment of Atrial Fibrillation and how they now differ somewhat from the European (ESC) Guidelines. The AHA/ACC/HRS Guidelines are an important reference for your cardiologist and electrophysiologist. Read my summary of his presentation including these key points:

Aspirin no longer recommended as first-line therapy (downgraded in the 2006 and 2014 guidelines);

Gender-bias in Guidelines?: Should every woman with A-Fib be given a point on the Guidelines risk scale?;

What Happens to Someone Taking Anticoagulants for Years?: Unlike what you hear in today’s advertising, anticoagulants are not like taking vitamins;

Concern About Leaving Patients in A-Fib: If you leave someone in A-Fib, you may never be able to get them back into sinus rhythm.

Learn must more from Dr. Calkins presentation. Read my AHA/ACC/HRS Guidelines summary report.

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

AF Symposium 2015

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

By Steve S. Ryan, May 2015

ECGI is changing everything—not only the way mapping and ablations are done, but also our basic understanding of A-Fib. Instead of potentials and CFAEs, EPs will focus on ablating drivers (rotors and foci). Ablating the PVs will still be basic. But in more difficult cases, EPs must look for non-PV triggers or drivers.

Prof. Michel Haïssaguerre of the French Bordeaux group/LIRYC gave a presentation entitled “Beyond PVI—Mapping and Ablation Techniques for Elimination of Drivers in Persistent AF.” Non-Invasive Electrocardiographic Imaging, or ECGI (from CardioInsight) is a radically new and innovative mapping and ablation system.

The ECGI Vest-Like Device Innovative Mapping and Ablation System

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

The day before their ablation, the patient lies down on their back and a technician places a vest-like device with 256 electrodes over their chest and stomach. These electrodes combine with rapid CT (Computed Tomography) scans to produce a very detailed 3D color map of the heart.

The system automatically detects rotors and foci and computes them into a “Cumulative Map” or movie. These driver regions are ranked, based on statistical prevalence. They are displayed in statistical density maps which define the ablation roadmap.

The use of ECGI mapping results in a drastic decrease of RF burns needed

The ECGI vest doesn’t directly record A-Fib signals from the septal regions. But Dr. Haïssaguerre showed slides where the septal drivers project onto the anterior and posterior attachments of the septum and are thus able to be mapped. For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging (ECGI).

Ablation using ECGI results in a drastic decrease of RF burns needed to produce A-Fib termination.

In ECGI, Paroxysmal and Persistent A-Fib Ablation are Different

Paroxysmal: Using ECGI in 41 paroxysmal patients, Dr. Haïssaguerre found that the A-Fib drivers originated from the PV/post LA region. They consisted of PV discharges interacting with short-lived ostial rotors, which is in accordance with current knowledge and practice of A-Fib ablation. (A standard PVI ablation normally targets these areas.)

Persistent: But in 248 persistent A-Fib cases (54% with Structural Heart Disease), he found multiple interplaying A-Fib drivers coming from both atria but usually clustered in 4 regions. (The regions could vary from 1-7.) These drivers were short lived (3-4 reentries/firings) but periodically recurred in the same areas. As one would expect, the number of driver regions increased with the duration of persistent A-Fib. Long-Lasting persistent had 7 driver regions diffused throughout the atria. Cases with only 1 driver region were rare (9%).

Relationship of Drivers and CFAEs

These driver regions overlapped with areas of CFAEs (Complex Fractionated Atrial Electrograms). But whereas CFAEs were found in 49% of the total atrial surface, drivers were found only in 19%. Also, fractionated signals were more frequent and spanned a greater part of the A-Fib cycle length in driver regions than elsewhere (71% vs 47%). (This is good news for patients with persistent A-Fib. With ECGI, much less heart area needs to undergo ablation burns.)

Best Ablation Outcome is A-Fib Termination, But Not Always Possible with Persistent A-Fib

Dr. Haïssaguerre showed slides where he ablated driver regions which transformed rapid complex A-Fib signals into slower organized signals. He stated from his own experience and from several studies that the best outcome of ablation was A-Fib termination into sinus rhythm or tachycardia.

But this result was much harder to achieve in long-lasting persistent A-Fib. In cases where patients had only recently went into persistent A-Fib (1-3 months), 75% had A-Fib termination targeting driver regions. While in long-lasting persistent A-Fib, only 13% had A-Fib termination. Dr. Haïssaguerre’s hypothesis was that early persistent A-Fib is initially driver-dependent, while long-lasting persistent cases progress to widespread substrate disease.

In another study following 90 patients, 85% of patients with A-Fib termination were A-Fib free after 12 months (in the remaining 15%, 54% were paroxysmal). While patients who didn’t have their A-Fib terminated, only 63% were A-Fib free (all were persistent).

What EPs Do When AF Persists After ECGI Driver Ablation

• Check driver regions (including PVs) to ensure abolition of rapid-disorganized EGMs (electrogram signals).

• Body Surface Remapping—to look for new drivers appearing after the first ones are eliminated. Many have observed that this strategy often improves results in difficult cases of long-lasting A-Fib.

Right Atrium Ablation

Dr. Haïssaguerre recommended ablating the right atrium after the left. Right atrium drivers can disappear after left atrium ablation.

Dr. Haïssaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers which are Multiple, Meandering, ShortLasting and Associated with Complex EGMs (electrogram signals).

• Ablation targeting these AF critical regions allows high rate of AF termination with minimal RF delivery.

• 85% AF freedom at one year when procedural AF termination is achieved.

• Reproducibility in 8 centers in Germany, Belgium and France (AFACART) (Eight centers in Europe are now performing ECGI ablations with similar results.)

Editor’s Comments:
Non-PV Triggers: If your EP only ablates the PVs, you should look elsewhere. I just read an O.R. (Operating Report) where the EP only CryoBalloon ablated the PVs. Even though the patient was still in A-Fib after the PVs were ablated, the EP didn’t look for non-PV triggers. He simply shocked the patient back into sinus rhythm and put him on an antiarrhythmic drug. Chances are the patient’s A-Fib will return, since the non-PV triggers in his heart weren’t ablated.
Driver regions overlap with CFAEs—CFAEs can be ignored: In difficult cases of A-Fib, EPs used to spend a lot of time mapping and ablating CFAEs. Sometimes there were so many CFAEs that the EP wound up debulking much of the left atrium. In Dr. Haïssaguerre’s research, CFAEs could cover nearly half of the total atria surface. But with ECGI, only 19% of that area is ablated. ECGI makes the EP’s job simpler and causes less burns on the patient’s heart.
Try to Get Out of Persistent A-Fib: If you haven’t done so already, ask your EP to be Electrocardioverted in order to avoid long-lasting A-Fib which causes atrial remodeling that produces widespread fibrosis and diffuse driver regions.
You may want to try the newer antiarrhythmic drug Tikosyn (dofetilide) which works well in some cases of persistent A-Fib. (When starting Tikosyn, you will have to be hospitalized for three days to get the dosage right and to check for bad side effects.)
Currently some long-standing A-Fib can’t be cured: The best outcome of ablation is A-Fib termination. But some long-lasting persistent cases turn into widespread substrate disease where it’s not always possible to map and ablate drivers. Even the famed Bordeaux group hasn’t yet figured out a way to achieve 100% success when ablating all long-standing persistent A-Fib.
If you have long-standing persistent A-Fib, should you just throw in the towel and give up? No. In Dr. Haïssaguerre experience, 63% of persistent patients who didn’t have their A-Fib terminated were still A-Fib free. You could be in that 63%. Just be realistic and don’t expect miracles.

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Last updated: Saturday, May 30, 2015

Risks of Cerebral Lesions & Cognitive Impairment: Living With A-Fib More Dangerous Than Having An Ablation

AF Symposium 2015

By Steve S. Ryan, PhD

Josef Kautzner MD

Josef Kautzner MD

Dr. Josef Kautzner of the Institute for Clinical and Experimental Medicine, Prague, Czech Republic gave a presentation entitled “Periprocedural Microembolization During AF Ablation—Mechanisms, Incidence and Clinical Significance.”

Dr. Kautzner’s agenda included demonstrating that living with “AF is more dangerous than its ablation.”

Silent Brain Lesions after Ablation?

Recent studies of mesh-type multielectrode catheters (not yet FDA-approved for use in the US) using MRIs of the brain have revealed silent cerebral ischemia—small lesions on the brain that don’t seem to produce any symptoms and tend to disappear over time. Worldwide experience suggests that small and medium lesions (less than 10mm) disappear at follow-up, while larger than 10 mm lesions remain. These larger lesions make up only a small proportion of the silent lesions found.

Dr. Kautzner pointed out that these silent lesions are common in many interventional procedures such as carotid artery stenting (37%) and TAVI (replacing the Aortic Valve) (68%-77%).

Though these small cerebral lesions don’t seem to cause symptoms, obviously doctors want to avoid creating any kind of lesions on the brain if at all possible.

Cognitive Dysfunction after Ablation?

…by 90 days the POCD rates had dropped down to 13% of paroxysmal and 20% of persistent.

In one study of “Post-Operative Cognitive Dysfunction (POCD)”, two days after standard ablations, about 25% of both paroxysmal and persistent patients experienced POCD, but by 90 days the POCD rates had dropped down to 13% of paroxysmal and 20% of persistent. No MRIs were done of these patients. (If this study had followed these patients for more than three months, the POCD rates for paroxysmal might well have dropped back down to near zero.)

Persistent patients had linear ablation lines added and ablation of complex fractionated electrograms (CFAEs). They also underwent more cardioversions during the procedure than paroxysmal patients. 1

Silent Brain Lesions Before Ablation of Greater Concern

Of greater concern are the silent brain lesions which occur frequently before ablation. In MRI tests, a high proportion of A-Fib patients before ablation had silent cerebral infarctions or lesions (60%-80%). But the problem is that similar lesions were detected by MRI even in patients without documented A-Fib. Therefore, we still do not know how much A-Fib contributes to the development of such lesions. On the other hand, their presence may explain (at least in part) the association between A-Fib and dementia.

We still do not know how much A-Fib contributes to the development of such lesions but their presence may explain the association between A-Fib and dementia.

In one study 89% of paroxysmal and 92% of persistent A-Fib patients had at least one area of SCI (Silent Cerebral Ischemia). The number of SCI areas was higher in patients with persistent A-Fib. These silent brain lesions are associated with dementia. 2

Cognitive performance was significantly worse in patients with paroxysmal and persistent A-Fib than in controls in sinus rhythm. 3

How Silent Brain Lesions Develop During an Ablation

Dr. Kautzner described how these lesions might develop:

• Thrombi due to activation of the coagulation cascade after introduction of catheters. That’s why heparin and other anticoagulants are used before, during and after an RF ablation
• Particulate emboli (char)—making RF burns can potentially produce charring where small particles of heart tissue can break off and travel to the brain. This can be prevented by catheter cooling (irrigated-tip catheters) and prevention of tissue overheating
• Gaseous emboli (micro-bubbles) produced by air on sheaths/catheters or by heating/boiling of blood and heart tissue “steam pops.” Prevention—as above

Preventing Silent Brain Lesions During an Ablation

Dr. Kautzner described the procedures his center follows to prevent silent brain lesions:

• If CHA2DS2-VASc score of 0-1, no prior anticoagulation
• All others have uninterrupted warfarin (persistent have TEE before ablation)
• Aggressive heparinization from the beginning of the procedure, immediately after venous puncture
• Use of intracardiac echocardiography to monitor the procedure

The success of these strategies was documented in a study where DW-MRI and protein S100B testing were performed both before and the next day after the ablation. (DW stands for Diffusion Weighted Imaging MRI which is more sensitive in detecting small & early infarcts [lesions or tissue deaths]).

S100B testing checks the blood for calcium-binding proteins coming from the brain after a stroke. They predict post-ablation brain injury.

S100B testing checks the blood for calcium-binding proteins coming from the brain after a stroke. They predict post-ablation brain injury. In the example from Dr. Kautzner’s center, 1.7% of ablation patients had a new MRI lesion, while 5% had an increase of plasma S100B. (Plasma S100B testing seems to reveal more potential brain damage than an MRI and is certainly easier and cheaper to perform.)

Predictors of Post-Ablation Brain Injury Detected by Plasma S100B Testing

• Persistent A-Fib
• Procedure duration
• Cumulative dose of heparin (ACT—Activated Clotting Time)
• Cardioversion during the procedure
• Age
• CHA2DS2-VASC score
• Amount of RF burns. Patients who had a simple PVI ablation had fewer silent lesions than if linear lesions had to be made. If ablation for CFAEs had to be made, they had even more chance of silent lesions
• Single vs two transseptal punctures

Proposed Strategies to Minimize Risk of Silent Lesions

• Avoid interruption of anticoagulation before ablation
• Use TEE or ICE to detect any thrombus
• Systemic heparin from the beginning of the procedure
• Meticulous management of transseptal sheaths and catheters (including submersion of sheath assembly when loading with special catheters to avoid air bubbles on the sheaths)
• If using phased mesh RF catheters, avoid simultaneous activation of overlapping electrodes
• Consider avoidance of cardioversion during the ablation

Dr. Kautzner’s Conclusions

• Post-ablation asymptomatic cerebral microembolism can be detected with variable frequency
• Clinical consequences are unclear—some studies suggest possible cognitive decline
• On the other hand, there is much stronger evidence that atrial fibrillation is associated with a substantial risk of asymptomatic cerebral lesions and cognitive impairment
• Assessment of procedure-related brain damage (using DW-MRI or protein S100B) should become a standard for the monitoring of safety of novel technologies for ablation

Editor’s Comments:
A-Fib More Dangerous to Cognitive Ability than its Ablation: We are most grateful to Dr. Kautzner for his comprehensive study of A-Fib silent brain lesions. The bottom line is that there is inconclusive evidence that ablations produce lasting linear brain lesions and cognitive decline.
On the other hand, we know from many studies that A-Fib (before ablation) produces silent brain lesions in nearly 90% of cases and that these silent lesions are associated with dementia. Cognitive performance is significantly worse in people with A-Fib (both paroxysmal and persistent). As Dr. Kautzner says, “A-Fib is more dangerous than its ablation,” with regards to silent brain lesions and cognitive ability.
Importance and Frequency of Silent Brain Lesions: I, and I think most of the attendees, were surprised at how prevalent silent cerebral lesions were in patients with A-Fib, and how A-Fib patients have significantly worse cognitive performance. This is yet another reason not to leave patients in A-Fib, and for those of us with A-Fib to get treatment and/or an ablation as reasonably soon as possible.

S100B testing seems a great way to test for brain damage

S100B Testing: S100B testing seems a great way to test for brain damage after an ablation. Most centers (and insurance companies in the US) won’t routinely do an MRI after an ablation. But an S100B plasma test is more easily and cheaply performed, and may be more accurate than an MRI. But then the question for doctors and patients is what should be done if a S100B test comes out positive? If there are no brain damage symptoms, how concerned should we be?

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Last updated: Friday, November 25, 2016

Footnote Citations    (↵ returns to text)

  1. Gaita, F et al. Prevalence of Silent Cerebral Ischemia in Paroxysmal and Persistent Atrial Fibrillation and Correlation With Cognitive Function. Am Coll Cardiol 2013:62; 1990-7.
  2. Vermeer, SE et al. N Engl J Med 2003;348:1215-22.
  3. Gaita, F et al. Prevalence of Silent Cerebral Ischemia in Paroxysmal and Persistent Atrial Fibrillation and Correlation With Cognitive Function. Am Coll Cardiol 2013:62; 1990-7.

‘Silent A-Fib’ More Dangerous Than ‘Symptomatic A-Fib’

Dr. John Camm of St. George’s Hospital

Dr. John Camm of St. George’s Hospital

Dr. John Camm of St. George’s Hospital in London, England discussed how silent (asymptomatic) A-Fib can have similar long-term effects as A-Fib with symptoms. Silent A-Fib may progress and get worse just like symptomatic A-Fib. But all too often people with silent A-Fib have a stroke and only then find out they have A-Fib.

Doctors today have a wealth of new A-Fib monitoring devices to detect A-Fib, such as the Medtronic Reveal DX which is inserted just under the skin and can monitor the heart for over a year, or the Zio Patch which you wear like a Band Aid for 1-2 weeks, or phone apps like the

AliveCor Heart monitor for SmartPhones.

BUT—how can we get heart monitors to the people who need them the most—people with silent A-Fib? Read more of Steve’s summary of Dr. Camm’s presentation->

AF Symposium 2015: Surprising Research on Fibrosis Using Sheep

Dr. Jose Jalife of the University of Michigan

Dr. Jose Jalife of the University of Michigan

A-Fib produces fibrosis (tissue that has fiber-like characteristics). Over time it makes the heart stiff, less flexible and weak). When Dr. Jose Jalife of the University of Michigan in Ann Arbor, MI, paced sheep into A-Fib, their hearts became fibrotic within a very short time and increased progressively as the sheep went from paroxysmal to persistent A-Fib.

Next, Dr. Jalife gave his sheep the a Gal-3 (protein) inhibitor. Learn the surprising results…Read more of my 2015 AF Symposium Report−>

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