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


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

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


Significant Research and Scientific Studies

2016 AF: Thickening of Left Atrium and Fibrosis Amount Predicts Outcome of A-Fib Ablation

AF Symposium 2016

Thickening of Left Atrium and Amount of Fibrosis Predicts Outcome of A-Fib Ablation

by Steve S. Ryan, PhD

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche, University of Utah (CARMA), is known for ground-breaking, thought-provoking research using MRI. His presentation was entitled “Atrial and Ventricular Myopathy: A Novel risk predictor for stroke and cardiovascular events.”

Amount of Fibrosis Better Predictor of Stroke Risk (and Heart Attack)

Dr. Marrouche began by showing how today’s stroke guidelines (CHADS2 or CHA2DS2-VASc) are mediocre predictive tools overall, according to most studies. Whereas atrial fibrosis detected by Delayed Enhancement-MRI (DE-MRI) is a better predictor of stroke risk.

DE-MRI stands for Delayed Enhancement Magnetic Resonant Imaging.

In Dr. Marrouche’s study, patients with more than 21% fibrosis had a 19.6% risk of stroke while those with under 8.5% fibrosis had only a 1% risk. The more fibrosis, the greater risk of clots forming in the Left Atrial Appendage (LAA).

In a study by King, higher levels of fibrosis were associated with ‘Major Adverse Cardiac Events’ (MACE), not only stroke but heart attack and deep vein thrombosis (a blood clot within a vein).

Cardiomyopathy and Fibrosis

Dr. Marrouche showed slides of normal atrial myocytes (muscle cells) vs. examples with extensive fibrosis where collagen replaced most of the red myocytes (which store oxygen until needed for muscular activity).

This is an important finding which may change the way we look at fibrosis.

This fibrosis correlated with abnormality of the atria (atrial myopathy) and deterioration of the ability of heart muscles to contract (cardiomyopathy). This is an important finding which may change the way we look at fibrosis.

(For further information on Dr. Marrouche’s work, see Higher Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation.)

Fibrosis/Myopathy Correlates with Atrial Strain

Dr. Marrouche showed slides of how the left atrium of an A-Fib patient with extensive fibrosis worked much harder to pump and had nearly three times more strain than a patient with mild fibrosis. (This may be why the left atrium often stretches and expands in remodeling.)

A-Fib Thickens Left Atrial Shape

In another ground-breaking observation, Dr. Marrouche showed slides of how the shape of the left atrium (LA) gets thicker as one progresses from no-A-Fib to paroxysmal to persistent A-Fib. In fact, in a study by Bieging, LA shape (thickness) is a strong independent predictor of outcome after AF ablation.

Left Atrial Appendage and Stroke Risk

Dr. Marrouche found that the Left Atrial Appendage (LAA) length, thickness and orientation correlate with stroke risk. These findings open up new avenues of research in A-Fib. Just looking at the LAA might produce an indication of stroke risk, which can be combined with other predictive measures.

Left Ventricular Disease Predicts Recurrence after Ablation Therapy

Some A-Fib patients also have a diseased Left Ventricle (LV) which shows up using ‘Late Gadolinium Enhancement- MRI’ (LGE-MRI). In a study by Suksaranjit, the recurrence rate after an ablation was 69% in patients with Left Ventricular LGE-MRI revealed disease, compared to 38% in patients without LV LGE-MRI. These patients also have more major adverse cardiac and cerebrovascular events.

Conclusion

Dr. Marrouche is now using both the amount of fibrosis and left atrial shape to stage and treat A-Fib patients. The main points we can learn from Dr. Marrouche’s research are:

Fibrosis makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems.

• Fibrosis puts you are greater risk of a stroke and other vascular problems.
• More fibrosis leads to thickened heart tissue, strains the heart and reduces the ability of the heart muscles to contract.
• A-Fib changes the thickness/shape of the left atrium.
• A-Fib can also change the length, thickness and orientation of the Left Atrial Appendage (LAA).
• Left Ventricular disease may accompany or be caused by A-Fib, be measured by MRI, and predict recurrence after catheter ablation..

What Patients Need To Know

Don’t delay! Your A-Fib leads to fibrosis! A-Fib produces fibrosis which is considered permanent and irreversible. Any treatment plan for A-Fib must try to prevent or stop remodeling and fibrosis.

Caveat: After reading Dr. Marrouche’s research and new insights that atrial fibrosis detected by DE-MRI is a better predictor of stroke risk (than CHADS2 or CHA2DS2-VASc), don’t rush into your EPs office asking about using MRI to diagnose your amount of fibrosis. Not every MRI technician and doctor has the special training and experience necessary to perform Dr. Marrouche’s testing. (And insurance companies may not want to pay for this testing. However, that may soon change.)

References for this article
King, JB et al. Association of atrial fibrosis with major adverse cardiac events in patients with non-valvular atrial fibrillation: abstract 16572. Circulation. 2015; 132:A16572. http://circ.ahajournals.org/content/132/Suppl_3/A16572

Beiging, Erik et al. LA shape is a strong independent predictor of outcome after AF ablation. 2015 Heart Rhythm Society.

Suksaranjit P et al. Incidental LV LGE on CMR imaging in atrial fibrillation predicts recurrence after ablation therapy. JACC Cardiovascular Imaging. 2015 Jul;8(7):793-800. http://www.ncbi.nlm.nih.gov/pubmed/26093929. doi: 10.1016/j.jcmg.2015.03.008. Epub Jun 17, 2015.

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A Watchman and Ablation Combo? Everything You Never Thought to Ask

by Steve S. Ryan, PhD

The Watchman device closes off the Left Atrial Appendage (LAA), the source of most clots and A-Fib strokes.

The Watchman has been available in other countries since 2009, but only since 2015 in the US.

Research tells us that the Watchman device is not only as good as but is actually better for A-Fib patients than being on the blood thinner warfarin.  (See my post: Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin)

Answers From Australia

A five-year study in Australia by Dr. Karen Phillips and her colleague, Dr. TW Walker, gives us ‘real world’ data and insights. Specifically, she studied combining the Watchman device with a catheter ablation for treating Atrial Fibrillation patients.

I’ve corresponded with Dr. Karen Phillips to help me answer your questions about the Watchman device.

“Can the Watchman be installed at the same time as my ablation?“

Yes.  Dr. Karen Phillips and several Electrophysiologists (EPs) in Europe have been doing this for over five years with no complications. She hasn’t seen any downside to doing the two procedures together. There’s very little, if any, experience in the US of combining a PVI with a Watchman device (US approved in 2015).

Should the Watchman be installed at the same time as my ablation?“

First answer: should the LAA be closed off? (Surgeons, unlike EPs, routinely remove the LAA in A-Fib surgery.) But the LAA isn’t a useless appendage and it has several functions. Younger people, especially the athletic, might be compromised by having their LAA closed off. (See LAA Important for Heart health.) There are many arguments for not routinely closing off the LAA in everyone. … Continue reading this report…->

2016 AF Report: Hot Topic—Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib

AF Symposium 2016

Hot Topic: Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib

by Steve S. Ryan, PhD

Rotors have become increasingly important in treating and ablating Atrial Fibrillation, particularly for Persistent A-Fib.

Rotors was such a hot topic, one could have called this year’s symposium the “2016 Rotor Symposium”.

If you have Persistent (or Long-standing A-Fib), you’ll want to seek out and be treated by EPs who understand rotors and recognize their importance.

Can Fibrotic Heart Tissue be Ablated?

Many EPs don’t ablate A-Fib patients with a high level of fibrosis and consider fibrotic areas as non-ablatable.

However, Dr. David Wilber of Loyola University Medical Center, Chicago, IL, found that patients with high levels of fibrosis can be successfully ablated by first examining the fibrotic areas for the presence of rotor circuits (i.e. A-Fib signal sources). Then, by ablating with both FIRM and high resolution optical mapping. This is a major new discovery.

Dr David Wilber Loyola University

Dr David Wilber Loyola University

In his presentation, “Impact of Atrial Fibrosis on Rotor Frequency and Location: Evidence from Combined Imaging and Mapping Studies,” Dr. Wilber began by examining a study by RS Oakes of 81 patients (50% had Paroxysmal A-Fib) which analyzed each patient using ‘Delayed-Enhancement Magnetic Resonant Imaging’ (DE-MRI).

Measuring Fibrotic Heart Tissue

Fibrotic heart tissue (scar tissue) is often found in patients with Atrial Fibrillation, particularly those with Persistent or Long-standing Persistent A-Fib.

DE-MRI is an MRI process which uses a metallic dye to see in 3D and identify fibrotic areas in the heart.

‘Delayed-Enhancement Magnetic Resonant Imaging’ (DE-MRI) can be used to precisely define scar tissue. As identified by DE-MRI, fibrotic heart tissue may be “low voltage”, that is, having little or no electrical activity.

In the Oakes research, “moderate” fibrosis was defined as heart tissue with 15%-35% fibrosis (low voltage) and was found in 30 patients. “Extensive’ fibrosis was defined as heart tissue with fibrosis greater than 35% and was found in 8 patients.

Fibrotic Patients and Persistent A-Fib

The Oakes study found that patients with moderate or extensive fibrosis were more frequently in Persistent A-Fib (70% vs 32%). This was true even when compared to factors such as expanded Left Atrium (LA) volume and having been in Persistent A-Fib before the ablation.

Intuitively, this makes sense. One would expect in the A-Fib remodeling process that patients with more fibrosis would be more likely to develop persistent A-Fib. (Perhaps extensive fibrosis is the reason Persistent A-Fib is harder to cure.)

Amount of Fibrosis and Recurrence Post Ablation

Dr. Wilber also discussed the DECAAF trial (see Marrouche High Fibrosis Precludes Catheter Ablation) which found fibrosis was the strongest predictor of recurrence after an ablation.

Rotors Anchored In or Located at the Edge of Fibrosis Regions

Dr. Wilber cited two additional studies. A study by BJ Hansen found that rotors are anchored to fibrotic areas of the heart. These rotor circuits can be identified and ablated by both FIRM and high resolution optical mapping. A study by McDowell found that the pattern or shape of fibrosis helps determine rotor formation.

Dr. Wilber’s Research on Left Atrium Rotors & Fibrosis

Dr. Wilber next presented his own research study. He and his colleagues used FIRM guided ablation in the examination of LA rotors and fibrosis. They first positioned the FIRM basket catheter in the right atrium and ablated rotors. They then moved to the left atrium and, after the FIRM rotor ablations, they performed a wide area circumferential Pulmonary Vein Isolation (PVI). They found more rotors (167) than focal sources (1).

Dr. Wilber and his colleagues found:

• 90% of rotor cores contained detectable fibrosis.
• The median regional fibrosis within individual rotor cores was only 13%.
• There was no relationship between the amount of fibrosis and both the number of rotors and the regional fibrosis of rotor cores.
• The mean amount of fibrosis in patients was 14.8%.

Summary and Conclusions

Summing up these research studies, Dr. Wilber concluded:

• The vast majority of rotor cores are associated with MRI detected fibrosis (90%)
• Measures of global atrial fibrosis do not predict number of identifiable rotors
• There is preferential location of rotor cores at the periphery of more dense regions of fibrosis
• Micro-anatomic distribution of fibrosis, and its impact on local electrophysiological properties, is likely to have additional influence on rotor formation, and specific sites of rotor stability.

Bottom-line for Patients with Persistent or Long-standing Persistent A-Fib

High Fibrosis Areas Can Be Ablated: While many EPs don’t ablate patients with a high level of fibrosis and consider fibrotic areas as non-ablatable, Dr. Wilber’s research shows that rotors (A-Fib signal sources) are located at or anchored in regions of fibrosis that can be ablated―particularly now that EPs know where to look for them. This may change the way mapping and ablations are done.

Good News: Patients with high fibrosis areas can be ablated.

The Amount of Fibrosis Doesn’t Predict the Number of Rotors: This is a surprising result (and needs to be confirmed by further study). This is good news for patients! Just because you have a lot of fibrosis doesn’t necessarily mean you have a lot of rotors (A-Fib signal sources). Your ablation won’t necessarily be more extensive than someone else’s.

What This Means to Patients: This fibrosis research is yet another reason for patients not to live in A-Fib! Living with A-Fib increases the risk of developing persistent A-Fib which is harder to cure. 

References for this article
Oakes RS et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation, 2009 April 7;119(13): 1758-67. http://www.ncbi.nlm.nih.gov/pubmed/19307477 doi: 10.1161/circulationaha.108.811877. Epub 2009 Mar 23.

DECAAF Trial: Delayed-Enhancement MRI (DE-MRI) Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01150214

O’Riordan, M. DECAAF: Targeting MRI-Identified Fibrosis During Ablation Improves Outcomes. Heartwire (Conference News).  Sept. 01, 2013. http://www.medscape.com/viewarticle/810308

Hansen BJ et al. Atrial fibrillation driven by micro-anatomic intramural re-entry revealed by simultaneous sub-epicardial and sub-endocardial optical mapping in explanted human hearts. Eur Heart J 2015 Sept. 14;36(35):2390-401. http://www.ncbi.nlm.nih.gov/pubmed/26059724. doi: 10.1093/eurheartj/ehv233. Epub 2015 Jun 8

McDowell, KS. Virtual Electrophysiological Study of Atrial Fibrillation in Fibrotic Remodeling. PLOS One, February 18, 2015. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117110. DOI: 10.1371/journal.pone.0117110

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2016 AF Report: 2 Challenging, Difficult Catheter Ablation Cases with LAA Closure

AF Symposium 2016

Steve Ryan at 2016 AF Symposium

Steve Ryan at 2016 AF Symposium

Two Challenging, Difficult Catheter Ablation Cases with LAA Closure

by Steve S. Ryan, PhD

One of the most interesting and practical sessions was “Challenging Cases in Catheter Ablation and LAA Closure for AF”.  Featured were a panel with some of the world’s ‘master’ Electrophysiologists (EPs). Each presented one or two cases of their most challenging and difficult cases from the past year. The panelists were:

• Dr. David Keane, St. Vincent’s University Hospital, Dublin, Ireland (Moderator).
• Dr. Moussa Mansour, Massachusetts General Hospital, Boston, MA.
• Dr. Andrea Natale, Texas Cardiac Arrhythmia Institute, Austin, TX
• Dr. Douglas Packer, Mayo Clinic, Rochester, MN
• Dr. Vivek Reddy, Mount Sinai Hospital, New York, NY
• Dr. Miguel Valderrabano, Houston Methodist Hospital, Houston, TX
• Dr. David Wilber, Loyola University Medical Center, Chicago, IL

Two cases of Persistent A-Fib stood out as significant for readers of A-Fib.com. To learn why, see my ‘Take Away’ comments that follow each case description.

Electrically Dead Left Atrium

Dr. Miguel Valderrabano

Dr. Miguel Valderrabano

Dr. Valderrabano presented the case of a 48-year-old female patient with symptomatic Persistent A-Fib. She had been cardioverted several times and had tried several antiarrhythmic drugs including amiodarone. She had had Pulmonary Vein Isolations (PVI) by other EPs before being referred to Dr. Valderrabano.

Her left atrium was enlarged. Dr. Valderrabano ablated her again but couldn’t isolate her Left Atrial Appendage (LAA) where A-Fib signals were still coming from. He used the Lariat (SentreHeart, Inc.), a noose-like suture delivery device, to close off and electrically remove her LAA.

After these steps, she had a leak from her closed-off LAA which had to be plugged. She was A-Fib free but developed Atrial Flutter which had to be ablated.

After all these ablations, she was finally in sinus rhythm. But at what cost? All the extensive ablations and scarring had made her Left Atrium electrically dead and unable to contract normally (“Stiff Left Atrium”).

The patient knew she might lose contraction of her left atrium, but was most happy to be in sinus rhythm after years of symptomatic A-Fib.

TAKE-AWAYS FOR PATIENTS

Lariat to Prevent A-Fib Signals from the LAA: The Lariat is an occlusion device, and like the Watchman, is normally used for closing off the Left Atrial Appendage (LAA) to prevent A-Fib clots breaking loose and causing a stroke. It’s particularly useful for people who can’t or don’t want to take anticoagulants.

In this case, the LAA was the source of non-Pulmonary Vein (PV) signals (and often is). By removing it, patients can often be restored to sinus rhythm. (Master EPs now consider the LAA the most important source of non-PV triggers. Unfortunately, many EPs are unaware of the LAA’s importance and don’t check it for non-PV triggers during an ablation.)

Stiff Left Atrium: No one wants to lose their Left Atrium’s ability to contract and pump. But in extreme cases, this may happen.

I talked to one of the most experienced EPS in the world who has had to do several ablations which restored a patient to sinus but also rendered their left atrium electrically dead and unable to contract normally. [Note: the Left Ventricle does most of the heavy-duty pumping work.]

His patients, even though they knew the risks, were overjoyed to finally be in normal sinus rhythm. After years of symptomatic A-Fib, they had their life back again.

FIRM Advantages and Problems

Dr. Vivek Reddy, Mt Siani Hospital

Dr Vivek Reddy, Mt Siani Hospital

Dr. Vivek Reddy presented the case of a 63-year-old male in Persistent A-Fib who had had several ablations before being referred to him. After wearing a Holter monitor for one-week, the data showed an A-Fib burden of 27%, i.e. his A-Fib was very symptomatic and burdensome.

Dr. Reddy did a FIRM-guided ablation, but the patient was still in A-Fib.

Upon closer examination and manual mapping, the ‘renegade’ A-Fib signal source was found and ablated, which restored the patient to sinus rhythm.

Dr. Reddy had discovered the A-Fib signal in the area where the FIRM basket catheter didn’t map. As mentioned in other Symposium presentations, due to design problems, the FIRM basket catheter maps only slightly more than ½ of the left atrium. (New basket catheters to correct this problem are being developed by the manufacturer, Abbott/Topera.)

TAKE-AWAYS FOR PATIENTS

Limited but Extensive Data with Fast Results: Even though the FIRM mapping and ablation system seems to currently have built-in limitations, master EPs still use the FIRM basket mapping catheter because it provides a great deal of important information very quickly. It is especially useful in cases of Persistent A-Fib where it identifies non-PV triggers such as rotors and focal drivers. As Dr. Reddy stated earlier, this is the future of A-Fib ablation.

Choose an EP Who Can Compensate for FIRM Limitations: When choosing an EP to do your ablation, it isn’t enough to select someone who uses the FIRM system. You need an EP who knows the limitations of the FIRM system and how to find and ablate non-PV triggers the FIRM system may miss. The fact that an EP uses the FIRM system is not a guarantee you will have a successful ablation.

Wrap Up

The two cases I chose to write about were the most informative for those A-Fib patients seeking to understand the most current treatment options. This Saturday afternoon session was the last of the 2016 AF Symposium.

For more about the Lariat occlusion device, see my brief article: Lariat II Suture Delivery Device.
For more about the FIRM mapping system, see my brief article: FIRM Mapping System—Should Ablation Patients Avoid It?

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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

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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.

Everyone 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.

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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.

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

 If you find any errors on this page, email us. Y Last updated: Tuesday, January 17, 2017

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.)

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

Is Cryoballoon as Effective and Safe as RF Ablation? A Clinical Study

There have been few randomization trials directly comparing CryoBalloon ablation to RF ablation.

That’s why Dr. Armin Luik and his colleagues developed the FreezeAF clinical trial―to directly compare CryoBalloon ablation to RF ablation for treating patients with paroxysmal atrial fibrillation. Dr. Luik (U. of Freiburg, Karlsruhe, Germany) presented the study results at the May 2015 meeting of the Heart Rhythm Society.

CryoBalloon catheter

CryoBalloon catheter

FREEZEAF Trial: Patients and Method

In the FREEZEAF study, 315 paroxysmal A-Fib patients with a mean age of 60 years were randomized to either a CryoBalloon ablation (n=156) or a RF ablation (n=159) of the pulmonary veins. Clinical follow up was at three, six, nine and 12 months.

The FREEZEAF Study Results

The FreezeAF trial researchers noted that a number of CryoBalloon ablation studies have demonstrated its efficacy and safety for treatment of A-Fib, but few studies have compared the two techniques head-to-head.

How did Cryoballoon compare to RF Ablation? … Continue reading this report…->

Resveratrol Reduces A-Fib Episodes in Animal Studies

Resveratrol is a natural and safe compound found in certain plants, has antioxidant properties and is known to improve cardiovascular health. It is found in red wine, red grape skins and seeds, peanuts and other foods.

Photo by Stoonn

Photo by Stoonn

A new medicine based on resveratrol, a ‘resveratrol derivative compound 1’ (C1), was effective in reducing the duration of A-Fib episodes in animal studies.

Dr. Peter Light of the University of Alberto, Edmonton, Canada published this study in the British Journal of Pharmacology. (This resveratrol research was funded by the Canadian Institute of Health Research and TEC Edmonton, with additional support from the Center for Drug Research and Development.)

How Does Resveratrol Work?

‘Resveratrol derivative C1’ seems to work by targeting multiple pathways involved in A-Fib, not just one or two as is the case with many current A-Fib drugs. These pathways include several ion channels as well as “pathways that cause adverse restructuring of the atria that may lead to A-Fib.”

Dr. Light thinks that the first in-human trials of ‘resveratrol C1’ may start in two-to-five years.

It’s highly unlikely that the ‘resveratrol derivative C1’ will be significantly better than natural resveratrol.

What This Means to A-Fib Patients

What’s important in this animal study is that a type of resveratrol reduced the duration of A-Fib episodes.

The beneficial effects of Resveratrol on cardiovascular health is well-documented. But, its usefulness for A-Fib patients requires more research. It’s possible Resveratrol could work as a ‘pill-in-the-pocket’ to reduce the duration or stop A-Fib episodes without the need for antiarrhythmic drugs.

Sources of Resveratrol

You don’t have to wait for Dr. Light’s trials to benefit from Resveratrol. (It’s highly unlikely that the ‘resveratrol derivative C1’ will be significantly better than natural resveratrol.) Resveratrol occurs naturally in red wine, red grape skins and seeds, grape juice, peanuts, mulberries, and some Chinese herbs. Resveratrol supplements are also available.

Caution: Resveratrol supplements could interact with medicines like blood thinners, blood pressure drugs, NSAID painkillers, and supplements like St. John’s wort, garlic, and ginkgo.

Talk with your doctor or healthcare provider before adding Resveratrol supplements to your diet.

To learn more about Resveratrol as a supplement, go the Memorial Sloan Kettering Cancer Center/Integrative Medicine database, About Herbs, Botanicals & Other Products, Resveratrol.

NOTE: In the US, substances found in nature like resveratrol cannot usually be patented by pharmaceutical companies and thus be under the control of the FDA. (This isn’t the case in other countries where natural substances are often regulated like drugs and consequently are often difficult to obtain.)

However, pharmaceutical companies can sometimes get around this restriction by making a change in the structure of a natural substance. Now it can be patented because it is no longer ‘natural’. Then it’s up to pharmaceutical reps to convince doctors to prescribe the patented version rather than the natural (and cheaper) substance.

References for this article
Marzo, Kevin. Blood thinner Antidote. Bottom Line Health, Volume 29, Number 9, September 2015, p. 1.Mundell, E.J.. Drug May Be Antidote to Bleeding Tied to Blood Thinner Pradaxa. Medline Plus. Monday, June 22, 2015. http://www.nlm.nih.gov/medlineplus/news/fullstory_153206.html

50-year Trends in Atrial Fibrillation: More A-Fib but Less Stroke

An analysis of 50 years of data from the Framingham Heart Study reveals good news and bad news for A-Fib patients.

Sadly, the number of people with A-Fib has more than quadrupled over the last 50 years!!!

But happily there was a 75% reduction in stroke rate (1998-2007 compared to 1958-1967). And, there was a 25% reduction in mortality after diagnosis of A-Fib.

What This Means to Patients: The Good News

A-Fib heart cloud Seek Your Cure 400 pix wide at 96 res with CC labelThanks in large part to warfarin (and the development of catheter ablation procedures), stroke rates over the years have declined by an amazing 75%. (Note: the new anticoagulants weren’t in use until after this study.)

As much bad press as warfarin has received and with all of warfarin’s bad side effects, we have to recognize that warfarin kept a lot of people from having a stroke. For years warfarin was the only game in town. Warfarin saved a lot of lives and disabling strokes.

New Therapies to Stop A-Fib and Prevent Stroke

The authors of this study talk about “therapeutic successes for atrial fibrillation” which have increased survival. Catheter ablation (and surgery) have certainly given A-Fib patients hope of a cure, when before all they could do is live with A-Fib and die from it.

New Anticoagulants (NOACs) Likely to Further Reduce Stroke Rate

The new anticoagulants (NOACs) will likely further reduce the A-Fib stroke rate. Eliquis, in particular, may be a major improvement over warfarin. Eliquis tested better with a better safety record than the other NOACs.

What This Means to Patients: The Bad News

Four times more people are developing A-Fib compared to the last five decades. A-Fib has rightly been called an epidemic. One out of four people over 40 will develop A-Fib in their lifetime. Today 1 out of 10 people over 80 years old has A-Fib.

Silent (no symptoms) A-Fib has emerged as a major killer. Of those who suffer a stroke, 20% later discover that they had silent A-Fib which probably caused their stroke.

The Good, the Bad and the Ugly

There has been a huge increase in the number of Electrophysiologists (EPs) performing catheter ablations to make people A-Fib free, thereby reducing their stroke risk to that of a normal person.

But even if all the EPs were perfectly trained and could work 24-hour days 7 days a week, they would barely put a dent in the huge number of new people developing A-Fib.

We may be facing a future where many new A-Fib patients may have to rely on drugs to cope with A-Fib.

But the current record for drug therapy isn’t good. There haven’t been any new antiarrhythmic drugs developed to stop A-Fib (with the possible exception of Tikosyn). Almost all current antiarrhythmic drugs either have bad side effects or aren’t effective for most patients. And if they do work, they often lose their effectiveness over time.

Takeaway

Don’t let this data discourage you. Seek your cure NOW. See an electrophysiologist about treatment options to cure your A-Fib.

References for this article
Harrison, Pam. Prevalence and Incidence of AF Increasing, but AF-Related Stroke Declining. The Heart.org. Medscape Multispecialty. July 15, 2015. http://www.medscape.com/viewarticle/848031.

Schnabel RB, Yin X, Gona P, et al. 50-year trends in atrial-fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: A cohort study. Lancet 2015; 386:154-162. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61774-8/abstract

Case Studies: Testosterone Cures A-Fib in Aging Men

Much media attention has been paid to the importance of testosterone in men and how testosterone levels tend to decrease with aging. But few studies have looked at how low testosterone affects A-Fib and A-Fib stroke risk.

Testosterone-ball-and-stick-model

Testosterone-ball-and-stick-model

Low Testosterone Can Cause or Trigger Stroke

Low Testosterone can be responsible for or trigger acute ischemic stroke, stroke severity, and related death in men, according to Dr. George Eby of the George Eby Research Institute. Low testosterone is also associated with coronary disease, myocardial infarction (heart attack) in men, and with all-cause mortality in men.

Case Studies: Testosterone Cures A-Fib in Aging Men

In an article in the journal, Cardiology, Dr. Eby described cases where Testosterone Therapy (TT) made aging men A-Fib free.

Case #1:  A 59-year-old man with a low Testosterone level of 361 ng/dl had daily A-Fib episodes for the last year. Other than PACs, he had no other heart problems.
Within 45 days of daily Testosterone Therapy (TT), his serum Testosterone rose to 1,489 ng/dl, and he had no instances of A-Fib and very few PACs. (After the second week of TT, his INR increased from 2.5 to 5.4 which required his Warfarin dosage to be lowered.)
 Case #2: A 59-year-old man had strongly symptomatic nocturnal paroxysmal A-Fib and depression. His serum Testosterone was only 150 mg/dl which is much lower than normal. Previously he had had congestive heart failure and persistent A-Fib which had been treated with ablation and cardioversion.
 He received both DHEA (25 mg/day) and natural testosterone (50 mg/day) as a gel applied to his shoulders. After Testosterone Therapy, his depression and ectopics ended with only two observed instances of A-Fib after two weeks.

Dr. Eby’s Conclusions

• “Testosterone Therapy (TT) is necessary, safe, and superior to antiarrhythmic drugs, and may prevent A-Fib and stroke in aging men.” According to Dr. Eby, “TT is a necessary, superior and safe natural rhythm treatment for A-Fib.” “TT may play an important role in treating A-Fib and preventing stroke in aging men.”

• “Testosterone is low in men with Lone A-Fib.” Testosterone has been shown to be low in men with lone A-Fib compared to non-A-Fib controls.

• “Beta-blockers lower testosterone [levels] in men.” Dr Eby also pointed out that beta-blockers lower testosterone in men.

• “Low Testosterone is a risk factor for stroke and death in men.” Testosterone is an independent risk factor for acute ischemic stroke, stroke severity, and related death in men. Low Testosterone is also associated with coronary disease and with myocardial infarction (heart attack) in men, and with all-cause mortality in men.

What This Means to Male A-Fib Patients

These may be the first reported cases of Testosterone Therapy for A-Fib and to prevent stroke in men. Obviously more research then a few case studies needs to be done on this subject.

If you are an aging man with A-Fib, you should have your Testosterone level checked. And for those with low Testosterone, raising your level, besides making you feel better and more youthful, may also prevent A-Fib and stroke.

References for this article

Eby, George. Cardiol 2007;1 17:c86-87. Doi:10.1016/j.mehy.2010.03.023

Lai j. et al. Reduced testosterone levels in males with lone atrial fibrillation. Clin Cardiol 2009;32:43-6. http://www.ncbi.nlm.nih.gov/pubmed/19143004. doi: 10.1002/clc.20423

Ravaglia, G. et al. Dehydroepiandrosterone-sulfate serum levels and common age-related diseases: results from a cross sectional Italian study of a general elderly population. Exp Gerontol 2002;37:701-12 http://www.sciencedirect.com/science/article/pii/S0531556501002327. doi:10.1016/S0531-5565(01)00232-7

Jeppensen LL et al;. Decreased serum testosterone in men with acute ischemic stroke. Thromb Vase Biol 1996;16:749-54. http://www.ncbi.nlm.nih.gov/pubmed/8640402.

Phillips, GB et al. The association of hypotestasteronemia with coronary disease in men. Arterioscler Thromb 1994;14:701-6. http://www.ncbi.nlm.nih.gov/pubmed/8640402.

AFACART Clinical Trial: Preliminary Results For Persistent A-Fib

Sébastien Knecht PMD PhD

My new 2015 AF Symposium report is of special interest for patients with persistent Atrial Fibrillation.

Dr. Sebastian Knecht from CHU Brugmann, Brussels, Belgium presented preliminary findings from the AFACART clinical trial testing the effectiveness of ‘Panoramic Electrographic Non-Invasive Mapping’, specifically the CardioInsight—ECVUE System, as compared to conventional mapping and ablation procedures.

In the clinical trial, patients with persistent A-Fib receive an ablation using the ECVUE mapping/ablation system, then there is a 12-month follow-up period.

In an important change to standard ablation procedures, Dr. Knecht described the first step in the ECGI/ECVUE ablation process as ablation of A-Fib drivers (rotors and foci).  This is in contrast to the ‘step-wise’ approach that begins with ablation of the openings of the pulmonary veins.

To read more, see my 2015 AF Symposium article, AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers.

Combining RF and CryoBalloon Ablation Techniques, Do Success Rates Increase?

Research Findings

Combining RF and CryoBalloon Ablation Techniques, Do Success Rates Increase?

by Steve S. Ryan, PhD, Updated October, 2016

Ross-J Hunter

Ross-J Hunter

Pulmonary Vein ablation (PVA), using RF point-by-point isolation, or using CryoBalloon technology? It is really a choice of one or the other?

What happens when you combine the two techniques? Do ablation success rates increase?

To answer these questions, UK researcher, Dr. Ross J. Hunter devised a single-center study to compare three different ablation strategies. He divided 237 Paroxysmal A-Fib patients undergoing their first ablation into three treatment groups.

Group 1 Strategy: standard RF point-by-point ablation of the Pulmonary Vein openings (PVs) using an irrigated tip catheter guided by a 3D mapping system.

Group 2 Strategy: CryoBalloon ablation using the Arctic Front CryoBalloon catheter, and if PV isolation wasn’t achieved using the CryoBalloon alone, RF focal lesions were added.

Group 3 Strategy: RF point-by-point ablation followed by two applications of the CryoBalloon.

Success Rates After One Year

Group 1:  At one year 47% were A-Fib free and off of all antiarrhythmic drugs; (This is a relatively low success rate compared to some centers using RF ablation.) Average procedure time was 211 minutes;

Group 2:  The one year success rate was 67% (significantly better than the RF group); Important Note: In addition to the CryoBalloon, 31% needed RF focal lesions to achieve PV isolation. Average procedure time was 167 minutes;

Group 3: After one year the success rate was 76% which was better than the CryoBalloon alone, but the difference wasn’t ‘statistically significant’ (meaning it could have occurred by chance). Average procedure time was 278 minutes.

The Study Results: How the Three Strategies Compare

Best result: Group 2 Strategy:CryoBalloon plus RF lesions as needed strategy’. It was faster, easier to use and was more effective after one year than the Group 1 strategy ‘RF point-by-point ablation’.

Disappointing result: Using the novel Group 3 strategy of combining ‘RF ablation followed by CryoBalloon ablation’ did not significantly improve results and took longer to do.

Most surprising result: When the authors designed this study, they thought the combined approach of ‘RF ablation followed by CryoBalloon’ (Group 3) would turn out to be superior to the other two strategies. Their prediction was wrong. It turned out it was only superior to ‘RF alone’  strategy (Group 1).

The Bottom Line

The take-away: About 30% of CryoBalloon ablations required RF focal lesions to achieve isolation of all A-Fib signals and to restore the patient to normal sinus rhythm.

What This Means for A-Fib Patients

For the best results with a CyroBalloon ablaltion, you want an electrophysiologist (EP) who is not only experiened with CryoBalloon, but who can also use RF technology when needed to map and isolate A-Fib signals originating beyond the pulmonary veins.

Finding the right EP: Be cautious. With the advent of CryoBalloon ablation, some EPs with little or no expertise with RF ablations are now doing CryoBalloon ablations. Why? Because they’re easier to perform. As a patient, you want to stay away from EPs who only do CryoBalloon ablation.

Here’s an example why:

Recently a patient, still in A-Fib, sent me the O.R. (Operating Room) report of their CryoBalloon ablation. From reviewing the report, after ablating the Pulmonary Veins (PV), it appears the EP didn’t make any attempt to map and isolate non-PV triggers. When the patient didn’t return to normal sinus rhythm on his own, the EP simply cardioverted the patient back into normal sinus rhythm. This may work in some cases. But for this patient the ablation was a failure.

Most experienced EPs who have switched from performing RF ablations to CryoBalloon ablations have the ability, skill and experience when needed to use RF technology to isolate non-PV triggers when needed.

Questions to Ask Prospective EPs: to find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?
Will you use RF techniques to get me back into normal sinus rhythm?

(You want an EP who answers ‘yes’ to the second question.)

References for this article
Dr. Ross J. Hunter is with St. Bartholomew’s Hospital, Bart Health NHS Trust & QMUL, London.

Hunter, Ross. Cryoballoon faster and more effective than conventional radiofrequency ablation for paroxysmal AF. Cardiac Rhythm News. Wednesday, May 14, 2014. http://www.cxvascular.com/crn-latest-news/cardiac-rhythm-news—latest-news/cryoballoon-faster-and-more-effective-than-conventional-radiofrequency-ablation-for-paroxysmal-af

Published on: Aug 12, 2015, Updated October 14, 2016

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

By Combining RF and CryoBalloon Ablation Techniques, Do Success Rates Increase?

Research: Combining RF and CryoBalloon Ablation Techniques

Combining RF and CryoBalloon Ablation Techniques

Research Findings

By Combining RF and CryoBalloon Ablation Techniques, Do Success Rates Increase?

RF point-by-point ablation for Pulmonary Vein (PV) isolation is technically challenging, time consuming, and the first-time success rate is variable. CryoBalloon ablation is easier and faster.

Question: What happens when you combine the two techniques? Do success rates increase?

To find out, UK researcher, Dr. Ross J. Hunter devised a single-center study to compare three different ablation strategies. He divided 237 Paroxysmal A-Fib patients undergoing their first ablation into three treatment groups.

Group 1 Strategy: standard RF point-by-point wide of the Pulmonary Vein openings (PVs) using an irrigated tip catheter guided by a 3D mapping system.

Group 2 Strategy: CryoBalloon ablation using the Arctic Front CryoBalloon catheter, and if PV isolation wasn’t achieved using the CryoBalloon alone, RF focal lesions were added.

Group 3 Strategy: RF point-by-point ablation followed by two applications of the CryoBalloon.

Success Rates After One Year

Group 1:  At one year 47% were A-Fib free and off of all antiarrhythmic drugs; (This is a relatively low success rate compared to some centers using RF ablation.) Average procedure time was 211 minutes;

Group 2:  The one year success rate was 67% (significantly better than the RF group); Important Note: In addition to the CryoBalloon, 31% needed RF focal lesions to achieve PV isolation; Average procedure time was 167 minutes;

Group 3: After one year the success rate was 76% which was better than the CryoBalloon alone, but the difference wasn’t ‘statistically significant’ (meaning it could have occurred by chance); Average procedure time was 278 minutes.

How the Strategies Compare

In this single center study, the CryoBalloon plus RF lesions as needed strategy (Group 2) was faster, easier to use and was more effective after one year than RF point-by-point ablation approach (Group 1). Using the novel strategy of combining RF followed by CryoBalloon ablation (Group 3) did not significantly improve results and took longer to do.

Editor’s Comments:
When the authors designed this study, they thought the combined approach of RF followed by CryoBalloon (Group 3) would turn out to be superior to either RF alone or CryoBalloon with RF as needed. But the combined RF followed by CryoBalloon strategy was only superior to RF alone (Group 1).
Key Result for Patients: The most important finding of this study is that about 30% of CryoBalloon ablations required RF focal lesions to achieve isolation (and restore normal sinus rhythm).
CryoBalloon ablation is very effective. But for the best results, you want an EP who is not only experienced with CryoBalloon, but also, when needed, can use RF to map and isolate non-PV triggers.
Be cautious. With the advent of CryoBalloon ablation, some EPs with little or no expertise with RF ablations are now doing CryoBalloon ablations because they’re easier. Stay away from EPs who only do CryoBalloon ablation.
For example, recently a patient, still in A-Fib, sent me the O.R. (Operating Room) report of their CryoBalloon ablation. From reviewing the report, it appears the EP didn’t make any attempt to map and isolate non-PV triggers, and simply shocked the patient to return him to normal sinus rhythm. This may work in some cases. But for this patient the ablation was a failure.
Most experienced EPs who have switched from RF to CryoBalloon ablation have the ability, skill and experience to use focal point RF as needed to make you A-Fib free.
Seek out these experienced EPs by asking “What do you do if I’m still in A-Fib after you do the CryoBalloon ablation? Will you use RF focal lesions to achieve isolation?”
References for this article
Dr. Ross J. Hunter is with St. Bartholomew’s Hospital, Bart Health NHS Trust & QMUL, London.

Hunter, Ross. Cryoballoon faster and more effective than conventional radiofrequency ablation for paroxysmal AF. Cardiac Rhythm News. Wednesday, May 14, 2014. http://www.cxvascular.com/crn-latest-news/cardiac-rhythm-news—latest-news/cryoballoon-faster-and-more-effective-than-conventional-radiofrequency-ablation-for-paroxysmal-af

Published Jul 14, 2015

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