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2023 AF Symposium: Challenging Case―An EP’s Nightmare
2023 AF Symposium
Challenging Case―An EP’s Nightmare
Dr. Karl-Heinz Kuck, Lubeck, Germany
Dr. Karl-Heinz Kuck of the University of Lubeck, Lubeck, Germany described the tragic case of a 77-year-old male who was a retired Cardiologist and a personal friend of his for over 40 years. This case resonated emotionally with both the panelists and the audience who seemed to have experienced similar experiences with their patients.
Persistent A-Fib―Successful Ablation
Dr. Kuck’s patient was suffering from persistent A-Fib since 2014. He had had a successful PVI (Pulmonary Vein Isolation/ablation) and roof line ablation in 2015.
A couple of weeks later, the patent had a repeat ablation including an isthmus line and was doing well for 6 years. But then he came back in with Tachycardia (high heart rate).
Dr. Kuck did another ablation in 2021. He found using voltage mapping that the patient had slow conduction around the scarring on the roof of the anterior wall. Among other techniques, Dr. Kuck made a roof line from the scar area to the annulus. He was able to terminate the tachycardia.
The patient was scheduled for a Left Atrial Appendage (LAA) closure procedure in 6 weeks. He was OK with that but didn’t want to come back for another ablation. He was told to continue taking anticoagulation.
Stops Taking Anticoagulation―Dies in 3 Days!
The patient stopped taking the anticoagulant apixaban (Eliquis) within a week of his ablation for fear of bleeding. He thought or was told by others or by his reading that he could substitute high dose aspirin for taking Eliquis. He was admitted at another hospital. A CT scan showed ischemia (an inadequate blood supply to the heart) and severe edema (swelling). He died 3 days later.
How to Prevent Patients Stopping Their Anticoagulation?
The audience was stunned.
An intense discussion among the panelists and the audience talked about why patients go off of anticoagulants when they shouldn’t.
People suffer a fall, develop cancer, have to have surgery, etc. and for various reasons are taken off of anticoagulants. Then they often develop a stroke.
During the discussion, some suggested closing off the LAA as soon as possible, even during an initial PVI ablation. The session’s last thought: “Should closing off the LAA be a first line procedure?”
Editor’s Comments
Nightmare of Patients Not Taking their Anticoagulant: Dr. Kuck’s case struck an emotional chord that resonated with attendees. A major nightmare EPs face is their patients not taking their anticoagulants, then having a stroke. This happens all too often and has probably occurred or will occur to every EP.
But, except for insisting that patients take their anticoagulants and other meds, there isn’t much an EP can do.
Closing Off the LAA May Be the Solution: Closing off the LAA does work and prevents stroke. It’s an effective substitute for a lifetime on anticoagulants. Then patients (and their doctors) don’t need to be preoccupied about a patient going off of anticoagulants. Instead of being a last resort procedure, many attendees seemed to think that LAA closure should be a first-line treatment for many patients.
If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023
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2023 AF Symposium: Live Case from Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter
2023 AF Symposium
Dr. Joseph Galvin, Dublin, Ireland
Live Case Presentation from Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter
The presenters of this live presentation were Drs. Joseph Galvin and Gabor Szeplaki from Mater Private Hospital in Ireland. They perform 800-900 ablations/year and have done 268 cases of Pulsed Field Ablation (PFA) using the Boston Scientific Farapulse system.
As we watched this live ablation, they used the optimized biphasic wave form for the PFA ablations. Dr. Szeplaki did the actual ablation while Dr. Galvin commented.
Dr. Gabor Szeplaki, Dublin, Ireland
No Lead Aprons
The first thing one noticed was that, instead of the typical Lead apron shields to protect against Fluoroscopy radiation, they were wearing what looked like plastic vests which were leadless. (Zero Gravity system by Biotronik.) These shields attach via a magnet to the operator who wears a vest with a magnet at the front.
66-Year-Old Female with Common Right Atrium
The patient was a 66-year-old woman who had developed symptomatic paroxysmal A-Fib three years ago. She had been taking Sotalol but tolerated it poorly. They also had tried dronedarone, but she had symptoms.
Her CHA2DS2-VASc score was 3. She had hypertension. Her left atrium was otherwise healthy. She had a somewhat unusual pulmonary vein anatomy with what looked like a huge common right ostium. They used general anesthesia rather than conscious sedation.
Ablation Procedure
NOACs (Novel Oral Anticoagulants) were discontinued the morning of the procedure.
A TEE (Transesophageal Echocardiogram) was used to make sure there was no thrombus (clot) in the heart.
They used Ultrasound to position the catheter to puncture the vein. In the heart they used a single transseptal puncture to access the left atrium. They used the Orion catheter for 3-D mapping and paced from the Coronary Sinus.
The mapping software was integrated into the Farapulse system in real time, which is a great help to the EPs. The catheter sheaths were transparent so that they could better see and eliminate bubbles on the catheters.
Farapulse catheter Open-Basket configuration
Farapulse catheter – Five Petal Flower configuration
Each vein to be ablated received four basket and four petal ablations rotating the catheter each time for better coverage. (For a more detailed description of the Farapulse system, see my 2020 report, Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.)
They made sure that both exit and entrance block were achieved in each vein. As they ablated, the heart tissue on the screen changed from light red to dark red.
Even with the large common right ostium, they still used the 31mm catheter rather than the larger size. The patient was successfully ablated and returned to normal sinus rhythm.
Overall their results in their center are 96% vein isolation and 84% curable PVI.
Dr. Galvin commented that when they first started, PFA ablations were taking 6-7 hours. But now they are doing them in 40 minutes.
Editor’s Comments
PFA Ablation Easy, Safe and Effective: The Farapulse ablation protocol has become relatively easy and safe to do. The operators in Ireland seemed very proficient, confident, and experienced. For them this was no big deal and almost routine. This is great news for patients. 40 minutes is a very short time to perform an ablation. And with no complications.
PFA Not Yet Approved in U.S.―But Will Be Soon. PFA ablation is not yet approved in the U.S., but has been approved overseas and has been in use for some time. Panelists from Germany pointed out that PFA ablation is now done on an out-patient basis with no need to stay in a hospital overnight. This is all good news for U.S. patients with Atrial Fibrillation.
Transparent Radiation Shields Great Advance: And using these transparent shields to protect against radiation exposure is a huge advance for EPs doing ablations.
I’ve been in operating rooms and had to wear those lead aprons used today by most EPs. They are really heavy and wear you down by the end of the day. All too many EPs develop slipped disks or other back problems. And reducing or eliminating radiation exposure improves EPs health and peace of mind. Good news for EPs!
If you find any errors on this page, email us. Y Last updated: Saturday, August 12, 2023
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2023 AF Symposium: Challenging Case―Ablates Hot Spots in Low Voltage Areas
2023 AF Symposium
Dr John Day, Salt Lake City, UT
Challenging Case―Ablates Low Voltage High Frequency Areas
Dr. John Day of the Heart Center of St. Mark’s Hospital in Salt Lake City, UT presented the case of a 56-year-old young man in otherwise good health. His BMI was normal. He had had an ablation but was still in A-Fib, according to his Apple watch. “Doc, I’m still having A-Fib. You’ve got to fix it.” He had mild or moderate left atrium enlargement but no clear A-Fib triggers. He didn’t want to be on drugs. He had tried Flecainide which lowered his heart rate too much. He couldn’t exercise on Flecainide.
Dr. Day gave the audience the following choices and asked their opinion.
1. End the case [with no further treatment]
2. Change the antiarrhythmic.
3. Ablate again.
Mapping illustration: Low-voltage high frequency areas targeted for ablation
The consensus of the audience was to ablate again. And this was indeed how Dr. Day proceeded.
Second Ablation of Hot Spots
In this patient’s second ablation, all the PVs (pulmonary veins) remained isolated. A-Fib was induced with pacing and Isoproterenol. Dr. Day used electrogram guided ablation.
When in both sinus rhythm and atrial fibrillation, the patient had low-voltage zones (suggestive of left atrial fibrosis) on the posterior wall of the left atrium.
Dr. Day targeted very high frequency signals (hot spots) appearing in low voltage areas. He remarked:
• “We only mark low voltage zones (diseased tissue) if it is low voltage in both sinus rhythm and atrial fibrillation.”
• “We only treat confirmed low voltage zones with high frequency signals…basically with this approach we are only treating diseased tissue with intense abnormal electrical activity which often corresponds to atrial fibrillation driver sites.”
Dr. Day admitted this doesn’t always work. But he has done over 5,000 ablations where this technique is effective.
The patient’s A-Fib didn’t terminate during the ablation, but it did later. Sometimes these patients have to be cardioverted to get them back into normal sinus rhythm.
This patient has been A-Fib free for 18 months and is off of Flecainide.
Editor’s Comments
Dr. Day and his colleagues may have developed a new method of making patients with difficult cases A-Fib free.
Innovation approach. Instead of looking for “potentials”, he ablates areas of low voltage and high frequency. This is an innovative approach and could help many patients with difficult cases.
If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023
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2023 AF Symposium: Spotlight Session on Laminar LAA Closure/Elimination Device
2023 AF Symposium
Dr. Saibal Kar of
Cardiovascular Associates
Spotlight Session: Laminar LAA Closure/Elimination Device
Perhaps the most innovative and potentially ground-breaking presentation at this year’s AF Symposium was by Dr. Saibal Kar of Cardiovascular Associates at Los Robles Hospital in Thousand Oaks, CA.
In a Spotlight Session on Friday, he described a new device for closing off (“eliminating”) the Left Atrial Appendage (LAA) where 90%-95% of Atrial Fibrillation clots and strokes come from.
2023 AF Symposium presentation session: Dr. Saibal Kar of Cardiovascular Associates at Los Robles Hospital in Thousand Oaks, CA.
Disappearing the LAA
In an animation by the company Laminar (Laminarlaa), Dr. Kar showed what he called a “rhythm ball”. It is inserted into the LAA, then twisted counterclockwise to the point where the LAA opening (ostium) is screwed together so tightly that the ostium disappears.
Then, this ball is locked in place to prevent it from unwinding. The closure/elimination is checked for leaks, then the catheter is released while the device remains locked in place.
Laminar LAA closure device
Dr. Kar refers to this process as not just closing off the LAA but eliminating it (in the animation, the LAA disappeared).
Quick to place: The whole process takes 16 minutes with testing taking only 60 seconds. All this can be done in real time.
Repositionable: If not satisfied with the original insertion, the device can be untwisted and repositioned.
Dr. Kar also showed implanted devices and how they look after 45 days. The LAA is closed off with only a very small ball left inside the LAA, much smaller than current LAA closure devices.
Two Years Testing, Two Centers in U.S.
The Laminar LAA Closure/Elimination device has been used in Europe for 2 years and is now in its third generation. European patients have had as many as 2 years of follow-up.
In the US, there are currently two centers performing this procedure, one at Los Robles hospital in Thousand Oaks, CA and a second in Tucson, AZ. In the U.S., 15 patients have received this device which has been 100% successful in closing off the LAA.
Editor’s Comments
Medical Breakthrough! The Laminar LAA elimination device is a potential medical breakthrough innovation!
Like many great innovations, the Laminar LAA elimination device seems remarkably simple and easy to use. It could revolutionize the way LAAs are closed off today. And because it takes so little time to insert, it could be positioned at the same time as a catheter ablation.
Most importantly, by actually eliminating the LAA rather than simply closing it off, it may be much better for patients offering fewer leaks, complications, intrusive metal devices in the heart, etc. Also, by actually eliminating the LAA, it could prevent non-PV triggers in the LAA from affecting a patient’s A-Fib.
In the future, current LAA closure devices such as the Watchman (Boston Scientific) and Amulet (Abbott) may be superseded by the Laminar device.
If you find any errors on this page, email us. Y Last updated: Friday, May 12, 2023
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2023 AF Symposium: Ablation Combines with LAA Closure in One Procedure
2023 AF Symposium
Ablation Combines with LAA Closure in One Procedure
Walid Saliba, MD
Dr. Walid Saliba of the Cleveland Clinic Foundation in Cleveland, OH, discussed an innovative treatment for A-Fib patients―combining A-Fib ablation with the insertion of a Left Atrial Appendage (LAA) occlusion device in a combined procedure. (This treatment strategy is currently in use in many countries overseas, but isn’t yet common practice in the U.S.)
Patient Selection
Dr. Saliba explained how patient selection is important in this combined procedure.
The idea patient with atrial fibrillation needing an ablation would also have a high risk of stroke but couldn’t tolerate anticoagulants because of a high risk of bleeding.
Advantages of Combining PVI with LAA Closure
While these two procedures (A-Fib ablation and LAA closure) are typically done separately, combining them in one procedure has many potential advantages. Both procedures:
• require access from the groin to the left atrium
• initiating oral anticoagulation around the time of the procedure
Dr. Saliba made the following points:
1.Combining these two procedures reduces the risk of complications. (For example, one only has to make a transseptal puncture once rather than at two different times.)
2. Patients prefer only having to have one procedure rather than the hassle of going to the hospital twice for two different steps.
3. Combining these two procedures reduces the potential risk of bleeding.
Reimbursement Problem in U.S.
Dr. Saliba described how in the beginning (2015) it was difficult to be reimbursed for combining two different procedures at the same time. But eventually he was able to convince the powers that be that this was good for certain patients and actually saved the hospital money.
Source of A-Fib Recurrences
Dr. Natale and Dr. Saliba discussed that many A-Fib recurrences come from the Left Atrial Appendage. Inserting an LAA occlusion device when performing an ablation might prevent the mapping and ablating of non-PV triggers in or around the LAA. (This is less of a problem with the Watchman than with the Amulet device which actually masks off the LAA area with a metal disc.)
High Success, Low Complication
Dr. Saliba and his colleagues at the Cleveland Clinic have performed this combined procedure on more than 240 patients with one-year follow-up. Their success rate is high with low complications. Patients stayed in the hospital for a day. Over 95% of their patients are eventually off of anticoagulants.
Half of their patients received the original Watchman, while the other half got the Watchman FlX. Leaks around the Watchman were only around 2.2% and were less than 2mm. At 90 days leaks were around 25% with less than 3mm. Dr. Saliba hasn’t noticed any problems with LAA remodeling, pressure, or scarring of the Left Atrium wall.
OPTION Trial Revelations to Come
The OPTION Trial is a clinical study of patients with non-valvular A-Fib. It compares outcomes of a combined ablation + LAA occlusion procedure versus catheter ablation alone followed with anticoagulation.
Specifically, the study is to determine if the WATCHMAN FLX occlusion device placed at the time of the ablation is a reasonable alternative to continuation of oral anticoagulation following catheter ablation. The results of this trial will be available in 2024.
Editor’s Comments
Combining PVI with LAA Closure Medical Breakthrough! Combining a catheter ablation for A-Fib (PVI) with the insertion of a Watchman occlusion device seems a major improvement for patients, as well as reducing or eliminating a major source of worry for electrophysiologists (EPs).
One day, hopefully soon, everyone getting a catheter ablation will also have an occlusion device inserted in one procedure.
Free from Most Stroke Risk: Inserting a Watchman device to close off the LAA has become a relatively simple and fast process. Combining it with a PVI doesn’t add much time to the ablation procedure. And Dr. Saliba’s research demonstrated that it works!
The Left Atrial Appendage (LAA) is where most clots and strokes come from in patients with non valvular A-Fib. Patients getting a catheter ablation generally leave the hospital A-Fib free.
Nevertheless, they are still considered at some risk of stroke. Current guidelines dictate continuation of stroke prevention with oral anticoagulation despite a successful ablation. Having the LAA closure device offers protection against stroke without the ongoing bleeding issues of oral anticoagulation.
Patients Would Choose/Prefer This Combination Procedure: If you offered the average A-Fib patient the chance to be protected from a stroke at the same time they are made A-Fib free by a catheter ablation, most patients would choose the combination procedure.
They would only have to be hospitalized once and wouldn’t have to return weeks later to have their LAA closed off, as is common practice in the U.S. today.
They would have better peace of mind and quality of life knowing they are largely protected from having an A-Fib stroke.
And their doctor wouldn’t have to worry about them going off their anticoagulant and developing a clot in their LAA.
If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023
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2023 AF Symposium: Reports for Patients by Steve S. Ryan, PhD
2023 AF Symposium
My Summary Reports Written for Atrial Fibrillation Patients
by Steve S. Ryan, PhD
The 28th Annual International AF Symposium took place Feb. 2-4, 2023 at the new Omni Hotel at the Seaport in Boston. Featured were presentations by 82+ leaders in AF research and clinical practice from all over the world. These stellar medical scientists, clinicians, and researchers shared recent developments in the A-Fib field in a major scientific forum unmatched by any other conference.
As always, I attend and write my reports to offer A-Fib.com readers the most up-to-date research and developments that may impact their treatment choices. All my reports are written in plain language for A-Fib patients and their families. Look for my reports here with links to the specific reports.
Read about the Annual International AF Symposium: Why I Attend Every Year & Why it’s Important to A-Fib Patients
| REPORT TITLE DATE | PRESENTER(S) | POSTED | |
| 6. | Challenging Case―An EP’s Nightmare | Dr. Karl-Heinz Kuck of the University of Lubeck, Lubeck, Germany | May 11,2023 |
| 5. | Live Case: Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter | Drs. Joseph Galvin and Gabor Szeplaki from Mater Private Hospital in Ireland | May 10, 2023 |
| 4. | Spotlight Session: Laminar LAA Closure/Elimination Device | Dr. Saibal Kar of Cardiovascular Associates at Los Robles Hospital in Thousand Oaks, CA. | May 10, 2023 |
| 3. | Challenging Case: Ablates Hot Spots in Low Voltage Areas | Dr. John Day of the Heart Center of St. Mark’s Hospital in Salt Lake City, UT | May 10. 2023 |
| 2. | Ablation Combines with LAA Closure in One Procedure | Dr. Walid Saliba of the Cleveland Clinic Foundation in Cleveland, OH | May 9, 2023 |
| 1. | Overview: 28th Annual International AF Symposium 2023 written by Steve S. Ryan, PhD | – – – | April 27, 2023 |
| Link to last year’s reports: 2022 AF Symposium Link to Archive of AF Symposiums Summaries by Year | |||
J. Ruskin
From Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School:
“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.”
If you find any errors on this page, email us. Y Last updated: Wednesday, June 21, 2023
2023 AF Symposium: My First Report for Atrial Fibrillation Patients
The 28th Annual International AF Symposium took place Feb. 2-4, 2023 at the new Omni Hotel at the Seaport in Boston. Featured were presentations by 82+ leaders in Atrial Fibrillation research and clinical practice from all over the world. These stellar medical scientists, clinicians, and researchers share recent developments in the A-Fib field in a major scientific forum unmatched by any other conference.
It’s a jam packed 2 1/2 days and affords me a unique opportunity to talk with and learn directly from many of the most eminent investigators in the field.
As always, I do this to offer A-Fib.com readers the most up-to-date research and developments that may impact their treatment choices. All my reports are written in plain language for A-Fib patients and their families.
Conference Snapshot: We might call this year’s Symposium “The Pulse Field Ablation” meeting.”
Most Noteworthy Quote: Dr. Daniel Singer of Massachusetts General Hospital in Boston, MA commented: “CHA2DS2-VASc is an embarrassment.”
Read my 2023 AF Symposium Overview and Introduction for highlights on this year’s conference. Other reports will follow shortly and will be announced here first.
You might want to visit and review my 2022 AF Symposium Reports.
2023 AF Symposium: Overview of My Summary Reports Written for Atrial Fibrillation Patients
Steve Ryan in Boston at the 2023 AF Symposium
2023 AF Symposium
My Summary Reports Written for Atrial Fibrillation Patients
By Steve S. Ryan, PhD
This 28th annual AF Symposium was held in Boston (where the AF Symposium originally started back in 1995). This intense 3-day seminar took place Feb. 2nd through 4th at the new Omni Hotel at the Seaport, a well-designed, ultra-modern conference venue. This Symposium featured presentations by 82+ leaders in AF Research and Clinical Practice from all over the world.
This is the 19th AF Symposium I have attended. It provides a unique learning experience about Atrial Fibrillation (A-Fib) not matched by any other conference. Attending the AF Symposium and adequately reporting on it is both a challenge and a privilege. I learn more in three days than in a year of reading the various A-Fib research reports.
The Pulsed Field Ablation (PFA) Meeting
We might call this Symposium the Pulse Field Ablation (PFA) meeting. Thirty of the 93 presentations were on PFA. 10 of the real time case presentations and 15 of the pre-recorded cases were on PFA. But most of the PFA strategies were not new and had been presented at previous AF Symposiums.
AF Symposium Turning Into a Tech Conference?
Compared to other AF Symposiums, this was primarily a tech conference heavily influenced by the industry. There were two informative Spotlight sessions on Thursday and Friday with 19 short presentations featuring new and future technology.
Sessions of 5+ presentations were sponsored by industry leaders such as Abbott, Boston Scientific, Medtronic, and Biosense Webster. (I personally miss the more patient-focused Seminars of previous years. But it’s hard to argue with the amount of money now provided by the industry to support the AF Symposium.)
Somewhat surprisingly there was only one presentation on drugs for treating Atrial Fibrillation.
Three representatives from the FDA attended and participated in the presentations and panel discussions.
Major Medical Breakthrough
Laminar LAA closure device
There was at least one major medical breakthrough and possible game changing presentation at the Friday Spotlight session. Dr. Saibal Kar of the Cardiovascular Institute of Los Robles Health System in Thousand Oaks, CA described a new Left Atrial Appendage (LAA) closure device from LAMINAR.
In an animation, Dr. Kar showed the LAMINAR device being inserted into the LAA, then twisted till it not only closed off but actually eliminated the LAA. Once the LAA was closed off, the device was locked in place so that you could barely see where the LAA had been.
This LAMINAR device could potentially revolutionize how the LAA is closed off. It seemed relatively easy to use and looked like it worked really well. But it’s still a long way from getting FDA approval.
Artificial Intelligence and Consumer Monitoring Devices
This AF Symposium documented how Artificial Intelligence is being applied to various treatments of Atrial Fibrillation. It also documented how consumer monitoring devices such as the Apple Watch and Kardia System are increasingly being used by patients and even their doctors.
But not always effectively. One EP (Electrophysiologist) described getting a call from an anxious patient at 2 a.m. alarmed that his Apple Watch showed he was having a short episode of AF.
Most Noteworthy Quote
Perhaps the most noteworthy quote of the Symposium was about the stroke-risk grading system (CHA2DS2-VASc) to help estimate the risk of stroke in patients with atrial fibrillation. Dr. Daniel Singer of Massachusetts General Hospital in Boston, MA commented: “CHA2DS2-VASc is an embarrassment.”
For further info on this topic, see our article The CHADS2 & CHA2DS-VASc Stroke-Risk Grading Systems.
The Omni Hotel Venue
The Omni Hotel is brand new and one of the best conference sites around. The staff was very competent and friendly. The Presentation and Exhibit halls were huge, architecturally well designed, and very impressive. The Exhibit hall was on the second floor with escalators to take you to the fourth floor Presentation hall.
(For some reason they shut down the escalators on Saturday, but one could still use elevators or stairs. Then late Saturday when most attendees had left, they turned the escalators back on. Go figure?)
One minor though annoying problem was that next to the Presentation hall was what seemed like a kind of kitchen. At times people working there made a lot of noise and talked/shouted so loud that at times they were as loud as or even occasionally louder than the presentation speakers. But this wasn’t a major distraction.
As one would expect in Boston in February, it was very cold. The temperature dropped to 9°F. To save money, I stayed at a (cheaper) hotel aways from the venue and thought my face would freeze off when I had to go outside. I won’t do that again.
AF Symposium Structure and Subject Presentations
Most presentations were 7 minutes long followed by a lively panel discussion. (If a presenter went over time, they heard a music cue which got progressively louder.)
• Panel and Audience Discussions were 25 minutes long.
• The “Spotlight Sessions” were 5 minutes long.
• There were 15 “Real-Time and Prerecorded Case Transmissions” which could run as long as 20 minutes.
• There were two debates.
My personal favorite session was the “Challenging Cases in AF Management (Drugs, Ablation, and Stroke Prevention)” which was the last Saturday presentation before the Symposium adjourned at 2:30 pm.
All went generally very smoothly. One has to compliment the organizers who did a remarkable job scheduling so many remote location presentations as well as 15 live and pre-recorded cases.
Program
Thursday, February 2
• Managing the AF Epidemic: From Prediction to Prevention and Access (5 talks)
• Spotlight Session I Early Stage and Emerging Technologies in Cardiac EP (10 talks)
• Real-Time and Prerecorded Case Transmissions-Session I (5 cases)
• Optimizing Lesions for RF Ablation in Atrial Fibrillation (5 talks) (Sponsored by an educational grant from Abbott)
• Stroke Risk Management in Atrial Fibrillation-Session I (5 talks) (Supported by an educational grant from Boston Scientific)
• Stroke Risk Management in Atrial Fibrillation-Session II (5 talks)
Friday, February 3
• Early Intervention for Prevention of AF Progression (5 talks)
• Spotlight Session II (9 talks)
• Real-Time and Prerecorded Case Transmissions-Session II (5 cases)
New Developments in RF Ablation for Atrial Fibrillation (3 talks plus a debate) (Supported by an educational grant from Biosense Webster)
• Innovations in Catheter Ablation for AF: Enhancing Efficiency, Effectiveness, and Workflow (3 talks plus a debate) (Supported by an educational grant from Medtronic)
• Pulsed Field Ablation Session I: Mechanisms and Technologies (5 talks)
• Late Breaking Clinical Trials and First Report Investigations and Best Abstract Award (5 talks followed by Best Abstract Award 2023)
Saturday, February 4
• Real Time and Prerecorded Case Transmissions-Session III (5 cases)
• Pulsed Field Ablation Session II: Clinical Outcomes of Pulsed Field Ablation for AF (5 talks)
• Pulsed Field Ablation Session III: Efficacy, Safety, and Future Directions of Pulsed Field Ablation (5 talks)
• Challenging Cases in AF Management (Drugs, Ablation, and Stroke Prevention)
• 2:30 PM Adjourn
International Real-Time and Prerecorded Cases Transmissions
The Cases Transmissions were again the highlight of the AF Symposium and the most well attended. It’s like “You Are There” in the lab with the EPs doing the procedure.
Thursday, February 2
• From Brussels, Belgium The Heart Rhythm Management Center “AF Ablation Using a Radiofrequency Balloon Catheter”
• From the Kansas City Heart Rhythm Institute, U.S. “Left Atrial Appendage Closure with the Amulet Device”
• From Mount Sinai Medical Center, New York, NY “Ultra-High Power Short Duration AF Ablation”
• From Sharp Memorial Hospital, San Diego, CA “Pulsed Field Ablation for AF Using a Circular Multielectrode Catheter”
• From Massachusetts General Hospital, Boston, MA “Pulsed Field Ablation for AF Using a 9mm Lattice-Tip Multielectrode Catheter”
Friday, February 3
• From Cologne, Germany University Hospital “AF Ablation with a New Generation Mapping System”
• From the Texas Cardiac Arrhythmia Institute, Austin, TX “Left Atrium Closure with Watchman and 4-D Interactive Ultrasound”
• From Brugge-Oostende, Belgium, St. Jan Hospital “Pulsed Field Ablation for AF Using a Multispline Catheter PFA”
• From Massachusetts General Hospital, Boston, MA “Pulsed Field Ablation for AF Using a Circular Multielectrode Catheter”
• From Homolka Hospital, Prague, Czech Republic “Pulsed Field Ablation for AF Using a Large Diameter Lattice-Tip Catheter”
Saturday, February 4
• From Dublin, Ireland, Mater Private Hospital “Pulsed Field Ablation for AF Using a Multispline Catheter”
• From Massachusetts General Hospital, Boston, MA “Left Atrial Appendage Closure with Watchman and a One-Step Transseptal Platform”
• From Tampa, FL, St. Joseph’s Hospital “AF Ablation Using a New Cryoballoon Catheter”
• From Hamburg, Germany “Pulsed Field Ablation for AF Using a Focal Tip Catheter”
• From Homolka Hospital, Prague, Czech Republic “Pulsed Field Ablation for AF Using a Spherical Multielectrode Catheter”
Awesome AF Symposium! More Reports to Come
Attending the AF Symposium and adequately reporting on it is both a challenge and a privilege. The AF Symposium brings together the world’s leading medical scientists, clinicians, and researchers who share recent developments in the A-Fib field.
Look for more of my reports from the 2023 AF Symposium in the next weeks and months. I’ll try to share with you the current state of the art in A-Fib research and treatments, what’s relevant to A-Fib patients and their families and friends.
In the meantime, you may want to browse my reports from the 2022 AF Symposium, or
the Archive of AF Symposiums Summaries by Year
During A-Fib Ablation Cooling Esophageal Reduces Injury
One of the very rare and dreaded complications of catheter ablation is Atrial Esophageal Fistula (1 case in 500 to 2,000+). Unlike most other ablation complications which are generally minor, temporary and easily resolved, a fistula can kill you!
Atrial Esophageal Fistula
How does this happen? The esophagus often lies just behind the posterior wall of the left atrium. During an ablation, heat from the RF (radio frequency) catheter applied to the back of the heart can damage the esophagus. (This can also happen during a Cryo ablation.)
If RF heat damages the esophagus, ulcer-like lesions form in the esophagus. In the 2-3 weeks following the ablation (post-ablation), gastric acids (reflux) can eat away at these lesions creating a fistula (hole) leading from the esophagus into the heart. Without major intervention, stomach contents can pass from the esophagus into the heart, leading to bloodstream infection (sepsis) and death.
Established strategies used to prevent esophageal injury include:
1. Reduce power applied to the vulnerable regions (Lesions with lower power may not always be effective.).
2. Monitor Esophageal temperature, stopping the ablation when temperature rises. (Note: This is a reactive approach of limited efficacy. By the time temperature rises, serious damage may have already been done to the esophagus.)
3. Deviate the esophagus during the ablation to bend it away from the area being ablated. (Can cause Esophageal trauma and involve difficulties in use. And requires procedural pauses for device manipulation.)
Cooling the Esophagus
“We know that most strategies (to prevent fistula) don’t work,” Says Dr. Mark Gallagher from St. George’s University Hospital in London, United Kingdom.
Illustration: Esophageal temperature management device
In an innovative and important research study reported at the 2020 AF Symposium, Dr. Mark Gallagher describes a cooling system used in the esophagus to prevent fistulas.
How does it work? In preparation for ablation of heart tissue, a 3-foot-long silicon soft tube is inserted into the patient’s esophagus. It’s connected to what is basically a refrigerator. Then whenever the EP (electrophysiologist) works near the esophagus, this closed loop system pumps cooled water (39.2 °F, 4 °C) down one loop of the tube, then back through another loop to the console. The EP controls the temperature.
Results of Using the Cooling System
A recent meta-analysis of esophageal cooling for the purpose of protecting the esophagus during RF ablation found a 61% reduction in high-grade lesion formulation in a total of 494 patients.
A recent randomized-controlled trial found a statistically significant 83% reduction in endoscopically identified lesions when using a dedicated cooling device compared to standard luminal esophageal temperature (LET) monitoring.
Another research study led by Dr. Marcela M. Montoya of Silico Science & Engineering S.A.S, Medellin, Colombia, found “the rapidly growing use of esophageal cooling during ablation has resulted in the publication or presentation of data on thousands of patients. Well over 10,000 ablations have now been completed with no Atrioesophageal fistula (AEF) formation yet reported and only a single pericardio-esophageal injury is known to have occurred.” (Pericardio-esophageal injury is a rarer and less severe subset of fistula formation.)
These various research studies show that cooling the esophagus works and is a major advance in the ablation of A-Fib.
Update 5/8/23:
Attune Medical reports that over 25,000 cooling devices were used in ablation procedures without a reported atrioesophageal fistula, and only a single pericardio-esophageal fistula known.
Editor’s Comments
Fistula Is a Major Emergency: A fistula is an all-hands-on-deck emergency involving not just the EP department but surgeons and many hospital staffers. A surgeon may have to perform emergency surgery to insert stents in the esophagus in order to close off the fistula, or the surgeon may have to cut out part of the damaged esophagus, which is particularly risky.
(I remember one EP describing how he and his staff were running down a hospital corridor with their fistula patient close to dying, in order to get the patient to an operating surgeon.).
Treating patients with a fistula is a huge expense and a nightmare for both EPs and hospital staff.
No More Threat of Fistula! Most fistula patients die. And for those who live through the emergency treatment, they are often compromised for life. But with the esophageal cooling system, patients and doctors may never again have to worry about the dreaded complication Atrial-Esophageal Fistula!
Cooling the Esophagus is a Major Medical Breakthrough! Cooling the esophagus is simple and relatively easy to do. And, barring future research findings, the system seems near foolproof, at least with typical ablation technique.
Esophageal Cooling Means Better Ablations: And as a bonus, using the esophageal cooling system enables EPs to do a better job. They can ablate all areas of the heart rather than avoiding areas too close to the esophagus or using lower power with shorter duration or less contact force. And procedure time is reduced, resulting in fewer complications.
List of Hospitals and Medical Centers using Esophageal Cooling
To assist you in seeking facilities offering esophageal cooling during Catheter Ablation for Atrial Fibrillation, I’ve compiled a list from my reference sources
This list is not an endorsement of any center, and is only offered for your convenience. Refer to Steve’s Directory of Doctors and Facilities for more information about a specific medical center or hospital.
Go to Steve’s List of Hospitals and Medical Centers using Esophageal Cooling
2022 AF Symposium: Reports for Patients by Steve S. Ryan, PhD
2022 AF Symposium
My Summary Reports Written for Atrial Fibrillation Patients
by Steve S. Ryan, PhD
From the NYC Marriott Marquis hotel and Times Square (the musical “Hamilton” was playing next door), the 27th Annual International AF Symposium was held from Thursday January 13 through Saturday January 15, 2022. 
The AF Symposium brings together the world’s leading medical scientists, clinicians, and researchers who share recent developments in the A-Fib field.
This is the 18th AF Symposium I have attended. It provides a unique learning experience about Atrial Fibrillation (A-Fib) not matched by any other conference. Attending the AF Symposium and adequately reporting on it is both a challenge and a privilege. I learn more in three days than in a year of reading the various A-Fib research reports.
As always, I do this to offer A-Fib.com readers the most up-to-date research and developments that may impact their treatment choices. All my reports are written in plain language for A-Fib patients and their families. Look for my reports in the weeks and months following the Symposium.
Read about the Annual International AF Symposium: Why I Attend Every Year & Why it’s Important to A-Fib Patients
| 10. | Pulsed Field Ablation for AF Using an Integrated Mapping and Ablation Spherical Array Catheter | Dr. Vivek Reddy from Mount Sinai Medical Center in New York City, NY and Dr. Petr Neuzil of Homolka Hospital, Prague, Czech Republic | Feb. 26, 2022 |
| 9. | Spotlight Session: Clinical Experience with the CLASS LAAO System | Dr. Jamie Kim of the Catholic Medical Center in Manchester, NH | Feb. 25, 2022 |
| 8. | Peri and Post Procedural Anticoagulation with LAA Closure Devices―An Evolving Story | Dr. Luigi Di Biase of the Albert Einstein College of Medicine, Bronx, NY | Feb. 21. 2022 |
| 7. | Spotlight Session: Calculating Left Atrium Wall Thickness | Dr. Saman Nazarian of the University of Pennsylvania in Philadelphia, PA | Feb. 20, 2022 |
| 6. | Abstract: Trial II of InCarda Orally Inhaled Flecainide | Christopher Dufton, PhD; InCarda Therapeutics, Inc. | Feb. 18, 2022 |
| 5. | Challenging Cases: The Patient has the Last Say | Dr. Eric Prystowsky of St. Vincent’s Hospital, Indianapolis, IN | Feb. 17, 2022 |
| 4. | Pulsed Field Ablation Using a Focal Electrode Catheter | Dr. Atul Verma of Southlake Regional Health Center in Toronto, Canada | Feb. 17, 2022 |
| 3. | In Development: Systems for Pulsed Field Ablation (PFA) | Dr. Moussa Mansour of Massachusetts General Hospital in Boston, MA | Feb. 15, 2022 |
| 2. | The LOOP Study–Implications for Clinical Practice and Future Trials | Dr. Andrea Russo of Cooper University Hospital in Camden, New Jersey | Feb 4, 2022 |
| 1. | Overview: 27th Annual International AF Symposium 2022 written by Steve S. Ryan, PhD | – – – | Jan 26,2022 |
| Link to my 2021 AF Symposium Reports Link to Archive of AF Symposiums Summaries by Year | |||
J. Ruskin
From Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School:
“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.”
If you find any errors on this page, email us. Y Last updated: Monday, May 15, 2023
