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

2021 AF Symposium

ATTEST Trial: Catheter Ablation to Modify Progression of AF

Dr. Karl-Heinz Kuck

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

Patient Risk: Progressing from Paroxysmal to Persistent A-Fib

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

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

The ATTEST Trial: RF Ablation vs Antiarrhythmic Drugs

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

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

ATTEST Findings

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

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

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

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

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

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

Dr. Kuck’s Conclusions

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

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

Editor’s Comments

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

Dr Paulus Kirchhof

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

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

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

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

2021 AF Symposium

Another Study Finds Ablation Better First-Line Treatment Than Medication

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

Dr. Jason Andrade

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

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

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

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

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

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

Additional Benefit: CryoBalloon Ablation Improved Quality-Of-Life

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

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

Editor’s Comments

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

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

Resources for this article

• A procedure, not medication, may be a more effective first-line of treatment for common heart rhythm problem. UBC Faculty of Medicine, November 24, 2020.

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

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

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2021 AF Symposium Spotlight Session: Drug in Development

2021 AF Symposium

Spotlight Session: Drug in Development

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

Dr. John Camm

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

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

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

Editor’s Comments:

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

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

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

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

2021 AF Symposium

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

2021 AF Symposium Live Streaming Video

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

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

The AFFERA System

The AFFERA system

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

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

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

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

Live Via Streaming Video

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

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

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

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

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

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

PFA Faster Than RF Ablations

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

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

Spacing Between Ablation Dots

Red dots are RF ablations; Green dots are PFA.

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

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

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

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

Why Use Both PFA and RF?

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

The Lattice catheter

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

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

Technical Achievement: The Lattice-Tip Catheter

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

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

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

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

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

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

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

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

Resource for this article

• Reddy, V.Y. et al. Lattice-Tip Focal Ablation Catheter That Toggles Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. Circulation: Arrhythmia and Electrophysiology, Vol. 13, No. 6.

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

Ablation Patients 10 Times Less Likely to Develop Persistent A-Fib Than Those on Drugs

Atrial Fibrillation is a progressive disease. For some that progress can happen quickly. For one in five patients, the path from Paroxysmal A-Fib (occasional) to Persistent A-Fib occurs within one year. (But there are people who’ve had Paroxysmal A-Fib for years.)

Delaying A-Fib Progression: Ablation vs Antiarrhythmic Drugs

The ATTEST study (The Atrial Fibrillation Progressions Trial) compared the treatments of radiofrequency (RF) catheter ablation versus standard antiarrhythmic drugs (AADs) in delaying A-Fib progression.

Patients were followed for three years. Of patients from the standard antiarrhythmic drugs group, 17.5% developed persistent A-Fib. While only 2.4% from the RF catheter ablation group experienced progression.

A-Fib Progression Delayed: The results at three years after study initiation show that patients treated with catheter ablation (aged 67.8±4.8 years) were almost 10 times less likely to develop persistent AF than patients on antiarrhythmic drugs.

“These results…suggest that early use of catheter ablation can significantly delay or prevent the progression of AF more effectively than drug therapy.”Prof. Karl-Heinz Kuck,” ATTEST lead author

The results of the ATTEST clinical trial aren’t at all surprising. It’s intuitive isn’t it? Someone free of A-Fib after a catheter ablation obviously wouldn’t progress to Persistent A-Fib—since they no longer have even occasional (paroxysmal) A-Fib.

The ATTEST study provides us additional clinical proof that catheter ablation may be a better treatment choice for most A-Fib patients compared to a lifetime on antiarrhythmic drugs (AADs).

Consider Working Aggressively to Stop Your A-Fib

Keep in mind there are people who’ve had Paroxysmal A-Fib for years and never progress to Persistent or Long-standing Persistent. But the odds are against you. The longer you have Atrial Fibrillation, the harder it can be to cure it.

Think About Your Treatment Goals: Is managing your A-Fib and increased stroke risk with meds okay with you? Or do you prefer to aim for a cure?

Discuss the options with your doctor. Take action as soon as practical.

For more about the ATTEST clinical trial, see AF Symposium ‘20 After Diagnosis, How Soon Should an A-Fib Patient Get an Ablation?

Resource for this article
ESC 2019: Catheter ablation may be up to 10 times more effective than drug therapy alone at delaying AF progression. Cardiac Rhythm News. September 2, 2019.

A-Fib is Progressive infographic at

Pre-Ablation Fitness Prevents Recurrence of Atrial Fibrillation

If you are physically fit before your catheter ablation for atrial fibrillation, you have a “much higher chance” of benefiting from the procedure and remaining in normal sinus rhythm (NSR). That’s the findings of a study from the Cleveland Clinic.

Less fit patients have more recurrence, are hospitalized more often, have to continue taking antiarrhythmic drugs longer, and have higher death rates.

Cleveland Clinic Physiology Fitness Study of A-Fib Patients (2012-2018)

In this study from the Cleveland Clinic, the participants were 591 patients scheduled to have their first catheter ablation for A-Fib.

Cardiorespiratory Fitness (CRF) relates to the ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity.

In the 12 months prior to their ablation, all were tested for fitness on a treadmill. Patients’ fitness was ranked as low, adequate, or high according to their Cardiorespiratory Fitness (CRF).

Astonishing Results: The Impact of Fitness

At 32+ months after ablation, findings among the three groups include:

Recurrence rate of:

• 79% of the low fitness group
• 54% of the adequate fitness group
• 5% in the high fitness group

Antiarrhythmic Drugs Use Discontinued in:

• 56% of the high fitness group
• 11% of the low fitness group

Mortality rate of:

• 11% of low fitness group
• 5% of high fitness group
• 4% of adequate fitness group


Other diseases such as hypertension, diabetes, and obstructive sleep apnea were similar across all three groups.

Study Implications

According to lead investigator Wael A. Jaber:

“Being fit is a great antiarrhythmic… . High physical fitness can keep you in rhythm after A-Fib ablation… . Being physically fit acted almost like a medication…”

Previous Studies about Exercise

Previous studies have shown that exercise, weight loss, and similar lifestyle modifications not only improve A-Fib symptoms, but in some cases even result in freedom from A-Fib.

Lack of fitness has been shown to predict A-Fib and arrhythmia recurrence.

Exercise, weight loss, and similar lifestyle modifications can improve A-Fib symptoms, and in some cases lead to freedom from A-Fib.

Dr. Prashanthan Sanders of Adelaide, Australia has described the great results he is getting in his clinic which includes a weight loss program and counseling. He convinces his overweight patients to buy into the program, lose weight, and keep it off.

The program works so well that just by losing weight patients become A-Fib free.

This program is a holistic approach to health and also is developed to work for diabetes, sleep apnea, hypertension, binge drinking and smoking.

Requiring or Recommending Fitness Program for A-Fib?

The Cleveland Clinic study is probably the first study to look at the effect fitness has on patient outcomes after ablation.

Physical fitness improves your A-Fib symptoms and ablation outcomes.

The results are so convincing we need to look at whether a fitness program before an ablation may alter and improve the chances of a successful A-Fib ablation. i. e., “survival of the fittest.”

For example, many A-Fib centers now routinely require patients with sleep apnea to get treatment before they can get an ablation.

Could this be done for patients with poor fitness as well? (Unfortunately, poor fitness is often a result of being in A-Fib with lower ability to exercise adequately.)

Managing Comorbidities: Many A-Fib centers now target the monitoring and improvement in blood pressure, glycemic control and weight loss in patients with A-Fib. Perhaps, better fitness and exercise capacity should probably be added to this target list, especially before an ablation.

More Study Data Needed: An important follow-up clinical study would be to determine whether modifying fitness prior to ablation improves outcomes.

Bottom Line for A-Fib Patients Considering Catheter Ablation

All A-Fib patients should work to be as fit as they can be. It’s especially important before a catheter ablation.

Exercise and manage any comorbidities. Address your sleep apnea. Lose weight and/or maintain a healthy weight. Eat a healthy diet and limit alcohol consumption. These life choices can reduce or help manage high blood pressure and diabetes.

Resources for this article

• Donnellan E, et all. Higher baseline cardiorespiratory fitness is associated with lower arrhythmia recurrence and death after atrial fibrillation ablation. Heart Rhythm. 2020 Oct;17(10):1687-1693. doi: 10.1016/j.hrthm.2020.05.013. Epub 2020 Aug 3. PMID: 32762978

• Fitness linked to lower arrhythmia recurrence after AF ablation. Cardiac Rhythm News. August 7, 2010.

New Research: Rhythm vs Rate Control Drugs for Atrial Fibrillation

Background: Back in the early days of A-Fib research, the 2002 AFFIRM study found no mortality difference between Rate Control and Rhythm Control. Though largely discredited today, many Cardiologists still use the AFFIRM study to justify keeping patients on rate control drugs (and anticoagulants), while leaving them in A-Fib. (If your Cardiologist tells you that, it’s time to get a second opinion.)

Results of Leaving Someone in A-Fib

A-Fib is a progressive disease. Just putting patients on rate control meds (even if they have no apparent symptoms) and leaving them in A-Fib can have disastrous consequences. Atrial Fibrillation can:

Remember: A-Fib is a progressive disease. 

• Enlarge and weaken your heart often leading to other heart problems and heart failure.

• Remodel your heart, producing more and more fibrous tissue which is irreversible.

• Dilate and stretch your left atrium to the point where its function is compromised.

• Progress to Chronic (continuous) A-Fib often within a year; Or longer and more frequent A-Fib episodes.

• Increase your risk of dementia and decrease your mental abilities because 15%-30% of your blood isn’t being pumped properly to your brain and other organs.

AFFIRM (2002) Study: Not Really an Endorsement of Rate Control Drugs

Dr Andrea Natale

Dr Andrea Natale

In the AFFIRM study, most of the rhythm control patients took antiarrhythmic drugs (AADs) to try to stay in sinus. Very few had catheter ablations. But AADs are known to have many toxicities which caused their own set of health problems and negatively influenced the results.

Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute/St. David’s Medical Center in Austin, TX pointed out that the AFFIRM study was not really an endorsement of Rate Control drugs.

Success of Antiarrhythmic Medications Borderline: According to Dr. Natale, the 2002 AFFIRM study illustrates how ineffective and dangerous current antiarrhythmic drugs can be.

“…data from several trials have demonstrated that the success of antiarrhythmic medications (AADs) in maintaining sinus rhythm is borderline, at best, with increasing failure rates over time… AADs clearly do not cure A-Fib; at best, they are a palliative treatment used to reduce the burden of A-Fib as opposed to eliminating it altogether. …in our experience rhythm control is not only ineffective and poorly tolerated, but only delays an inevitable ablation.”

“…In our experience rhythm control is not only ineffective and poorly tolerated, but only delays an inevitable ablation.”

The AFFIRM study didn’t compare patients in Rate Controlled A-Fib with patients in Normal Sinus Rhythm (the goal of catheter ablation).

Study Conclusion: In fact, the AFFIRM investigators concluded, “the presence of sinus rhythm was one of the most powerful independent predictors of survival, along with the use of warfarin…Patients in sinus rhythm were almost half as likely to die compared with those with A-Fib.”

New Study Confirms Rhythm Better Than Rate Control

EAST-AFNET 4 stands for The Early Treatment of Atrial Fibrillation for Stroke Prevention Triall;  It started in 2011.

The EAST-AFNET 4 trial studied 2,789 patients with early A-Fib (and other cardiovascular conditions). They were randomized to either early rhythm control or rate control (“usual care”).

“Early rhythm control” included treatment with antiarrhythmic drugs or atrial fibrillation catherter ablation. Patients were included if they were diagnosed less than a year before enrollment (median time since diagnosis was 36 days).

Duration of Study: Patients were followed for about five years. The primary outcomes examined were death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome (first primary outcome).

Study Results: The early rhythm-control strategy proved superior to rate control and was associated with a lower risk of adverse cardiovascular outcomes than usual care.

Editor’s Comments:

We should not be surprised that rhythm control proved better for patients than rate control.
Let’s bury the 2002 AFFIRM study once and for all!

Remember: A-Fib is a progressive disease. Leaving people in A-Fib while just trying to control their rate (symptoms) is imprudent and over time can be very harmful to A-Fib patients.

Resources for this article
Wyse DG, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. doi: 10.1056/NEJMoa021328. PMID: 12466506.

Kirchhof, P. et al. Early rhythm-control therapy in patients with atrial fibrillation. (EAST-AFNET 4 trial). N Engl J Med., 2020 August 29.

Debate “Catheter Ablation should be first line therapy in selected patients with A-Fib” Boston AF Symposium, January 13-14, 2006.

Book Review: “Your Complete Guide to AFib” by Percy Morales, MD

Review by Steve S. Ryan, PhD

I received an advance copy of “Your Complete Guide to AFib―The Essential Manual for Every Patient With Atrial Fibrillation” by Dr. Percy Morales and asked for a review. The opinions given are my own.

Caveat: $149.95 to be Cured of AFib

Abbreviations for Atrial Fibrillation include: AFib, A-Fib and AF.

Dr. Morales’ book encourages readers to sign up for his “” program at $149.95 a pop. It’s very surprising to see a medical doctor engage in a direct marketing-type sales hustle. His “Guide to Healthy Living” reads like a Tony Robbins motivational presentation but applied to AFib.

[I personally was very discouraged and depressed reading Dr. Morales’ work.]

Style of Dr. Morales’ Book

“Your Complete Guide to AFib” is written by a working Electrophysiologist (EP). It’s a thin book, 119 pages, without a lot of content. But what’s there is clear and based on Dr. Morales’ own experience.

In terms of style, Dr. Morales’ book is a dull read with too many proofreading errors for such a small volume.

Instead of standard footnotes, he cites actual web sites which doesn’t work well. (Website addresses and pages change every day. As a solo source, they are not a reliable one.)

Is There No Cure for AFib?

A major shortcoming of Dr. Morales’ book is he doesn’t acknowledge that AFib can be cured, that you don’t have to live in AFib. This is discouraging and a turn-off for many readers. He isn’t big on hope.

Causes of AFib

Under “Causes of AFib” Dr. Morales doesn’t discuss or acknowledge Lone AFib where people who are perfectly healthy get AFib and don’t have any comorbidities (around 50% of AFib cases, including me) (p. 16). But on page 99 he does acknowledge that, “some younger patients will be diagnosed with AFib where there is no clear cause for it.”

Most people who develop AFib are not sick with other diseases. And even if one is sick with, for example, high blood pressure, we can’t say for sure that high blood pressure “caused” a particular person’s AFib.

Is AFib Your Fault?

Dr. Morales implies that it’s a patient’s fault that they developed AFib, because they let themselves get sick with “comorbidities” which brought on their AFib (p. 16). … Continue reading this book review..->

Catheter Ablation for Atrial Fibrillation Prevents Recurrence Compared to Drugs

Several recent research trials and studies have demonstrated that up to 94% of patients with Atrial Fibrillation treated with catheter ablation are free from arrhythmia recurrence at one year.

And, with nearly one-half the chance of death, stroke, cardiac arrest, and cardiovascular hospitalization when compared to patients on antiarrhythmic drugs (AADs).

In addition, these studies show that catheter ablation could significantly improve patient quality-of-life versus a treatment strategy of drug therapy. (Also, ablation is a more cost-effective option over the long term.)

Recurrences Attributable to Comorbidities (Other Illnesses)

With so many catheter ablations for A-Fib being performed worldwide (some estimate over one million preformed last year), it’s inevitable that anecdotally you’ll hear of people having recurrences.

Comorbidities raise risk of A-Fib recurrence

Comorbidities raise risk of A-Fib recurrence

But recurrences are often attributable to comorbidities such as diabetes, sleep apnea, high blood pressure, obesity, etc.

For example, if you come in with sleep apnea, some centers won’t allow you to have a catheter ablation till you get the sleep apnea problem under control, because of the threat of recurrence.

To lower your risk of recurrence after a successful ablation, aim to avoid other health problems. Address your sleep apnea. Lose weight and/or maintain a healthy weight. Stay fit, eat a healthy diet and limit alcohol consumption. These life choices can reduce the risk of developing high blood pressure and diabetes.

Staying in generally good health (and avoiding comorbidities) will lower your risk of recurrence of your A-Fib.

Why Not to Fear Recurrence: Consider a Worst-Case Scenario

For a moment, let’s discuss a worst-case scenario. At age 60 you are diagnosed with Lone A-Fib (no comorbidities) and have a catheter ablation which makes you A-Fib free.

It lasts 10 years. But think. For all those 10 years, you’ve know what a blessing it is being in normal sinus rhythm (NSR).

If your A-Fib recurs it’s not the end of the world. You and your doctor will deal with it.

Then, at age 70, your A-Fib returns. After a short touch-up ablation (which probably filled in some gaps that appeared in the ablation lines), you’re once again A-Fib free. And, you will probably live in normal sinus for the rest of your life.

(This scenario worked out pretty well, don’t you think.) If your A-Fib recurs it’s not the end of the world. You and your doctor will deal with it.

For A-Fib Patients Reluctant About Catheter Ablation

The track record for successful catheter ablation to treat Atrial Fibrillation is impressive. And continues to outperform treatment with antiarrhythmic drugs (AADs).

While recurrence does happen, it’s mostly after years of living A-Fib free in normal sinus rhythm. If that happens, often it only requires a “touch-up” ablation to get back once again in normal sinus rhythm.

It makes no sense to not have a catheter ablation because of some remote possibility you might have a recurrence!

On a Personal Note

My 21-year Catheter Ablation ‘Warranty’ Ran Out! 

My A-Fib returned in Sept. 2018. Recurrence didn’t come as much of a surprise. Back in 1998 my ablation was primitive compared to what EPs are doing today. They actually ablated inside just one of my pulmonary veins (PVs) to eliminate the A-Fib signal source. -> Read how Steve Ryan’s became A-Fib-free again.

Resource for this article

• Biosense Webster, Inc. Announces Catheter Ablation May Be up to 10 Times More Effective Than Standard Drug Therapy Alone at Delaying Progression of Atrial Fibrillation. October 3, 2019. ESC Congress

• ESC 2019: Catheter ablation may be up to 10 times more effective than drug therapy alone at delaying AF progression. Cardiac Rhythm News. 2nd September 2019.

• Philips, T. et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. doi: 10.1093/europace/eux376

• Johnson &Johnson, October 3, 2019. Biosense Webster, Inc. Announces Catheter Ablation May Be up to 10 Times More Effective Than Standard Drug Therapy Alone at Delaying Progression of Atrial Fibrillation.

Additional Sources:

• Hussein A, et al. Prospective use of Ablation Index targets improves clinical outcomes following ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2017. 28 (9): 1037-1047.

• Taghji P, et al. Evaluation of a Strategy Aiming to Enclose the Pulmonary Veins With Contiguous and Optimized Radiofrequency Lesions in Paroxysmal Atrial Fibrillation: A Pilot Study. JACC Clin Electrophysiol 2018. 4 (1): 99-108.

• Phlips T, et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. Europace 2018. 20. (FI_3): f419-f427.

• Solimene F, et al. (2019) Safety and efficacy of atrial fibrillation ablation guided by Ablation Index module. J Interv Card Electrophysiol 2019. 54 (1): 9-15.

• Di Giovanni G, et al. One-year follow-up after single procedure Cryoballoon ablation: a comparison between the first and second generation balloon. J Cardiovasc Electrophysiol 2014. 25 (8): 834-839.

• Jourda F, et al. Contact-force guided radiofrequency vs. second-generation balloon cryotherapy for pulmonary vein isolation in patients with paroxysmal atrial fibrillation-a prospective evaluation. Europace 17 2015. (2): 225-231.

• Lemes C, et al. One-year clinical outcome after pulmonary vein isolation in persistent atrial fibrillation using the second-generation 28 mm cryoballoon: a retrospective analysis. 2016. Europace 18 (2): 201-205.

• Guhl EN, et al. Efficacy of Cryoballoon Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol 2016. 27 (4): 423-427.

• Irfan G,  et al. One-year follow-up after second-generation cryoballoon ablation for atrial fibrillation in a large cohort of patients: a single-centre experience. 2016 Europace 18 (7): 987-993.

• Boveda S, et al. Single-Procedure Outcomes and Quality-of-Life Improvement 12 Months Post-Cryoballoon Ablation in Persistent Atrial Fibrillation: Results From the Multicenter CRYO4PERSISTENT AF Trial. JACC Clin Electrophysiol 2018.  4 (11): 1440-1447

Research: Catheter Ablation for Atrial Fibrillation Lowers Risk of Dementia

In an important study from South Korea, researchers found that patients undergoing a successful catheter ablation for A-Fib had a reduced risk of dementia. Previous research had shown that A-Fib was linked to an increased risk of dementia.

Sinus Rhythm Reduces Dementia

Intuitively one would think that going from A-Fib to normal sinus rhythm would increase and improve blood flow to the brain, thereby improving brain function. And indeed, in this retrospective study, catheter ablation reduced the incidence of dementia by nearly a third (27%) compared to those who tried to control their A-Fib with medication alone.

Alzheimer’s disease is one type of dementia.

Using data from South Korea’s National Health Insurance Service, they identified 9,119 patients who had ablation and 17,978 who received medical therapies. During the follow-up period (6-12 years) there were 164 cases of dementia in the ablation group and 308 cases in the medical therapy group. Ablation was linked to a 23% lower incidence of Alzheimer’s disease and a 50% decrease in vascular dementia compared to medical therapies.

Ablation was linked to a 23% lower incidence of Alzheimer’s disease and a 50% decrease in vascular dementia compared to medical therapies.

Ablation Reduced Dementia by 44%!

According to one of the lead researchers, Dr. Gregory Lip of the University of Liverpool (UK), “…successful ablation was significantly associated with a 44% reduced risk of dementia compared to medical therapy…”

Improved Blood Flow Reduces Alzheimer’s

What’s perhaps most important about this study is the reduced risk or incidence of Alzheimer’s disease after a successful catheter ablation for A-Fib. When people develop Alzheimer’s, it’s considered the end, that there’s very little that can be done to help these patients. But restoring blood flow to their brains seems to prevent or reduce Alzheimer’s.

Can we prevent or reduce Alzheimer’s by improving blood flow to the brain? Could these researchers have discovered a way to cure or improve Alzheimer’s? This could be ground-breaking research!

Resource for this article
Catheter ablation linked to lower incidence of dementia in AF patients, Cardiac Rhythm News. October 7, 2020.

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