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“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. 

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


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"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...."

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Cavanaugh Heart Center, 
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"...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."

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Rome, Italy

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


Catheter Ablation

A-Fib Patients: Know Your Risk During Non-Cardiac Surgeries

For patients with Atrial Fibrillation, any surgery is riskier than for patients without A-Fib. That’s the finding of a 2022 study.

In a study from the Cleveland Clinic, patients with A-Fib undergoing non-cardiac surgery were associated with higher risks of mortality, heart failure, and stroke.

“Non-cardiac Surgery” means any surgery that doesn’t involve the heart.

Study Parameters: Non-cardiac surgery was classified as vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. (Basically any major surgery not involving the heart.)

Participants included 8,635,758 Medicare patients admitted from 2015 to 2019 for various surgeries not involving the heart (non-cardiac surgery). Out of this number of patients, 16.4% of patients had A-Fib at the time of their surgery.

For patients with Atrial Fibrillation, any surgery is riskier than for patients without A-Fib.

Focus of the Study: Did post-surgery adverse events differ for A-Fib patients compared to the other participants?

Findings: The study found that pre-existing A-Fib is independently associated with postoperative adverse outcomes after surgery. These include increased risk of stroke, heart failure and other heart-related complications.

Editor's CommentsEditor’s Comments

Established Protocols: There are well established and known protocols to prevent, diminish or neutralize A-Fib when undergoing noncardiac surgery. The researchers, Waterford and Ad, state that preoperative oral amiodarone is the single most powerful intervention to dramatically reduce rates of POAF.
They recommend 400 mg oral amiodarone per day for 3 days prior to surgery, followed by 200 mg per day for 10 days through and following the operation regardless of whether or not POAF developed. It’s recommended that a patient be on a beta-blocker or a statin whenever possible.
Ideally, Become A-Fib Free Before the Surgery: If you have A-Fib and have to undergo non-cardiac surgery, try to become A-Fib free before the surgery. (This is even more important if undergoing cardiac surgery such as bypass).
Medication Adjustment: Even if you can’t have a catheter ablation, your EP can often adjust your meds so that you are A-Fib free at the time of the noncardiac surgery.
Proper Pre-Op Treatment: If it isn’t possible to be A-Fib free before the your surgery, make sure your surgeon knows about and uses protocols to prevent and diminish the effects of A-Fib on non-cardiac surgery. See Having Surgery? Post-Operative A-Fib & Protocols to Prevent it.
Be Insistent! Be Assertive! Be aware that many surgeons (and their staff) don’t know about or use these protocols.
If you’re told by the surgeon’s office staff to “Don’t worry about that.” or “The surgeon is very experienced,” don’t settle for platitudes.
You may have to be very assertive with your surgeon to make sure they understand your concerns and treat you properly before the surgery.

It’s Okay to Fire Your Surgeon: If your surgeon won’t work with you, there are many surgeons who will. It’s okay to fire your surgeon, and find another one who will address these concerns.

References
• Prasadam S. et al. Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery. JACC Journals, Vol. 79 No. 25. https://www.jacc.org/doi/10.1016/j.jacc.2022.04.021

• Waterford and Ad. 7 Pillars of Postoperative Atrial Prevention. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. Editorial. November 25, 2021. https://pubmed.ncbi.nlm.nih.gov/34823388/ doi: 10.1177/15569845211043485.

Parlay an Ablation to Keep Dementia Away

I have written about studies documenting that A-Fib leads to or causes dementia. How A-Fib doubles the risk of dementia. And that there’s a direct cause and effect relationship, independently relating A-Fib to cognitive decline and dementia.

Good news! A recent research study tells us there’s a way to break that link.

Observational Study: Ablation Reduces Dementia

In a fascinating observational study from Turin, Italy, catheter ablation for A-Fib was associated with a nearly 50% reduction in dementia during a 4.5-year follow-up.

The researchers looked at four observational studies from 2020-2021 that included 40,146 patients of whom 11,312 had catheter ablation for A-Fib.

Compared to patients who developed dementia, they found having a catheter ablation for A-Fib reduced the risk of developing dementia by 50%!

Researchers concluded: ”Correct management of the arrhythmia holds the potential to delay or avoid cognitive decline occurrence.”

Important Research Findings for Patients with A-Fib!

We know that going from A-Fib to normal sinus rhythm increases and improves blood flow to the brain. So it’s intuitive to suppose that improving brain function would reduce the risk of dementia.

A-Fib patients who have a catheter ablation may now add another benefit to becoming A-Fib free, they may also significantly reduce the risk of developing dementia!

Seek Your Cure and a Two-For-One

If you have A-Fib, don’t settle for a life on meds. Don’t just “manage” your A-Fib. Seek your Cure.

A two-for-one! If your path to a cure includes a catheter ablation, you may also be reducing your risk of developing dementia. That’s a double whammy!

Research
Saglietto A, et al. Association of Catheter Ablation and Reduced Incidence of Dementia among Patients with Atrial Fibrillation during Long-Term Follow-Up: A Systematic Review and Meta-Analysis of Observational Studies. J Cardiovasc Dev Dis. 2022 Apr 30;9(5):140. doi: 10.3390/jcdd9050140. PMID: 35621851; PMCID: PMC9143892.

Pulsed Field Ablation Proves Safe Without Cerebral Complications

We have written many articles on Pulsed Field Ablation (PFA), a new and very effective treatment option for the ablation of A-Fib. (For a background on PFA, see my post: Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.)

PFA continues in clinical trials, is awaiting FDA approval in the U.S. (expected in 2024), and is already in daily use in some countries.

Previous studies have shown that PFA performs catheter ablation effectively with no adverse effects, such as coronary artery stenosis, persistent phrenic nerve palsy, or esophageal damage. PFA doesn’t damage surrounding non-cardiac tissue.

But what about cerebral damage?

Thermal (RF) Ablation: Silent Cerebral Lesions

When using thermal ablation (Radio Frequency), procedure-associated stroke, while rare, can be among the most severe disabling complications of RF ablation.

Recent studies using magnetic resonance imaging (MRI) have shown the occurrence of silent cerebral lesions and/or events with possible cerebral complications using RF ablation.

Are there cerebral complications with Pulsed Field Ablation as the energy source?

Pulsed Field Ablation: No Neurological Problems

In a small (though probably definitive) study from Germany, 30 patients with symptomatic paroxysmal A-Fib received a Pulmonary Vein Isolation using Pulsed Field Ablation energy. Stroke scores, using the National Institutes of Health Stroke Scale, were assessed before the ablation and afterwards at 2 days and 30 days.

One day after receiving their Pulsed Field Ablation, patients underwent a cerebral MRI. Of patients, 97% showed no silent cerebral lesions or events. One patient did have a single, newly visible, asymptomatic, transient brain lesion. But forty days after the procedure, a follow-up MRI scan showed complete regression of the lesion.

None of the patients receiving the Pulsed Field Ablation had any neurological deficits.

Editor's CommentsEditor’s Comments:

Yet another study demonstrating the neurological safety of Pulsed Field Ablation (PFA). This study from Germany, used MRI to detect possible brain damage and found that PFA produced no neurological problems.
In practical terms, PFA is safer than current ablation energy sources.

Pulsed Field Ablation is a true game changer! I repeat my previous prediction that Pulsed Field Ablation will supersede all other types of catheter ablation for A-Fib.

Reference
Reinsch, N. et al. Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation. Science Direct, Heart Rhythm, Available online 17 June 2022. https://www.heartrhythmjournal.com/article/S1547-5271(22)02090-2/fulltext. https://doi.org/10.1016/j.hrthm.2022.06.018

 

My A-Fib Update: Touch-Up Ablation and Closure of My Left Atrial Appendage

Background: I received my first catheter ablation back in 1998 at Bordeaux, France where they invented the procedure. (I was their first US patient.) After this ablation, I was A-Fib free for over 21 years. This is an update to my own A-Fib story (Story #1 under Personal A-Fib Stories of Hope.)

In 2018 my GP detected an irregular heartbeat, though I was unaware of it and had no symptoms. I had a Medtronic Reveal LINQ Insertable wireless loop recorder/monitor installed. (See Has My A-Fib Returned?)

Steve Ryan with Dr. Natale and his nurse before his ablation.

It eventually showed that my A-Fib had reoccurred−at age 80. This wasn’t surprising to me since my ablation procedure back in 1998 was primitive compared to what’s being done today. At that time, none of my Pulmonary Veins (PVs) were completely isolated.

I had a “modern” ablation in 2019 and was much improved. But my loop recorder showed Very Late Recurrence of A-Fib—I still had paroxysmal A-Fib.

Very Late Reoccurrence and the Left Atrial Appendage (LAA)

Recent research shows that the Left Atrial Appendage (LAA) is responsible for a great deal of A-Fib recurrence, (See LAA Under-Recognized Trigger).

Dr. Andrea Natale performed my re-do, touch-up  ablation on August 19, 2021 at Los Robles Hospital in Thousand Oaks, CA. He isolated both my LAA and coronary sinus and other areas of my heart which had developed non-PV triggers. (See A-Fib Free Again.)

Need to Close Off My LAA

Unfortunately, the ablation work done on my LAA reduced its ability to contract properly. I was aware of this potential problem and discussed it with Dr. Natale. Because my LAA wasn’t contracting properly, there was a greater danger of forming an A-Fib clot there. But instead of going on heavy-duty anticoagulants for life, I opted fer a Watchman occlusion device to close off the LAA. So, a few weeks later I had the Watchman installed.

A-Fib Free, Once Again!

After my LAA was closed off I was on ½ dose Eliquis for a while. They also did a CT scan June 27, 2022 to make sure the Watchman was seated properly and didn’t have any leaks.

I’m now once again, A-Fib free! All is well.

My Battery Died!

LUX-Dx implantable loop monitor

My doctor continues to monitor my heart through my LINQ loop recorder (a tiny cardiac monitor implanted just under the skin near my heart). In June, the battery on my 3 year old Reveal LINQ loop recorder died. I now have a newer version (Boston Scientific LUX-Dx). It was installed by Dr. Shephal Doshi at St. John’s in Santa Monica, CA on July 7, 2022. This one should last 4½ years.

Technology marches on! My old loop record used a recording/transmitting device at my bedside. This new one seamlessly sends the daily data to my cell phone, then to Dr. Doshi for review. All has been quiet since.

Editor’s Comments

Editor's Comments

A-Fib Recurrence is Discouraging, But it Happens. It’s certainly discouraging to have A-Fib reoccur after 21 years. But on the positive side, I had 21 years of being A-Fib free! I was able to lead a normal, very active life (running, sprinting, high jumping, lifting weights, swimming, participating in track meets, etc.) I didn’t worry about A-Fib reoccurring and was surprised when it did at age 80. (In cancer research, anyone who is in remission for 5 years is considered cured. The same should hold for A-Fib.)
Why Does A-Fib Reoccur? We don’t know why A-Fib reoccurs in a small number of patients. It’s probably related to aging. But the good news is that EPs today know how to fix it and restore people to normal sinus rhythm.
Running on All Cylinders! I’m back to normal, running with no A-Fib. I may have lost some heart pumping ability when my Watchman was installed to close off my LAA. But it doesn’t seem to have much of or any effect. Curing my A-Fib was much more important.  My speed isn’t what it used to be. But I am 81 years old and also had to have my left hip replaced two years ago which by itself made me seconds slower.
The bottom line is that, even though at age 81 I’m well past “my expiration date”, I’m in great health and am very active. I can’t thank enough all the EPs and researchers who made this possible.
Select an EP Who Maps and Ablates the LAA.  No matter what kind of A-Fib you have, if closing off your LAA, make sure your EP knows how, is experienced at, and routinely maps and ablates the LAA. This may produce a more successful ablation and save you from a recurrence of A-Fib.
Concurrent Installation? Today, there is a trend toward closing off the LAA at the same time as your catheter ablation. If you are considering a catheter ablation, I urge you to discuss this issue with your EP.
To learn more about the Left Atrial Appendage, see my article, The Role of the Left Atrial Appendage (LAA) & Removal Issues.

Click on photo to browse the over 100 patient stories of Personal A-Fib Stories of Hope.

Study of Dementia Risk: Catheter Ablation for A­-Fib Versus Drug Therapy Alone

Historically, dementia in patients with A-Fib was attributed to strokes.

Recently it has become clear that A-Fib is associated with multiple forms of dementia even in the absence of stroke.

… A-Fib is associated with multiple forms of dementia even in the absence of stroke.
According to research, dementia may be attributable to alterations in neurological hemodynamics and brain activity that are associated with both dementia and depression.

As anyone with an aging loved one suffering from dementia can tell you, dementia is a major health problem. In the U.S., dementia is predicted to affect more than 10.5 million Americans by 2050.

Research: Risks of Ablation vs. Drug Therapy

In an observational study, researchers compared A-Fib patients who had a catheter ablation to those treated with drug therapy alone.

They used the 2010 to 2021 data from a large, nationally representative claims database (Optum Clinformatics Data) to identify 19,088 A-Fib patients. They then divided these patients into two groups: those receiving a catheter ablation vs those receiving anti-arrhythmic drug (AAD) therapy alone.

Findings: Risks of Dementia and Mortality

Dementia Risk: They found that catheter ablation for A-Fib was associated with a 41% lower risk of dementia compared to patients treated only with anti-arrhythmic drug therapy. This dementia risk reduction held across both males and females.

A lower Mortality Risk means you are less likely to die prematurely from one cause versus any other cause of death.

Mortality Risk: Though not studied as a primary outcome, researchers found patients treated with catheter ablation also had a 49% lower rick of mortality compared with anti-arrhythmic drug therapy only.

What This Means to Patients

Catheter Ablation, by reducing the risk of dementia by 41%, is a major advance in our knowledge about health care for A-Fib patients.

This is yet another reason to get a catheter ablation ASAP in order to be A-Fib free.

Research
Zeitler, E. et al. Comparative risk of dementia among patients with atrial fibrillation threated with catheter ablation versus anti-arrhythmic drugs. Science Direct, American Heart Journal, Available online 20 September 2022. https://www.sciencedirect.com/science/article/pii/S0002870322001922. https://doi.org/10.1016/j.ahj.2022.09.007.

A-Fib and Dementia: Neither is a normal part of growing older.

2023 AF Symposium: Live Case from Dublin using Pulsed Field Ablation and Multispline Catheter

LIVE live from Dublin, Ireland—it was like we were in the EP lab with Drs. Joseph Galvin and Gabor Szeplaki from Mater Private Hospital in Ireland.

They perform 800-900 ablations/year and have done 268 cases of Pulsed Field Ablation (PFA) using the Boston Scientific Farapulse system. Amazingly, these ablation average 40 minutes in length—a very short time to perform an ablation (and no complications).

The patient was a 66-year-old woman who had developed symptomatic paroxysmal A-Fib three years ago, medications were poorly tolerated.

The first thing we noticed was, instead of the typical Lead apron shields to protect against Fluoroscopy radiation, they were wearing what looked like plastic vests which were leadless (but did provide radiation protection).

As we watched from Boston… . Read my full blow-by-blow report, see Live Case Presentation from Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter.

2023 AF Symposium: Challenging Case―An EP’s Nightmare

This is a tragic case of a 77-year-old male, a retired Cardiologist and a personal friend of the speaker for over 40 years. This case resonated emotionally with both the doctors, panelists and the audience who seemed to have experienced similar experiences with their patients.

Dr. Karl-Heinz Kuck of the University of Lubeck, Lubeck, Germany, described what lead up to a fatal climax.

The story starts in 2014 when his patient developed Persistent Atrial Fibrillation. He had a successful PVI (Pulmonary Vein Isolation/ablation) and roof line ablation in 2015.

A couple of weeks later, the patent had a repeat ablation including an isthmus line. He was doing well for 6 years. But then he came back with… Read the whole story at Challenging Case―An EP’s Nightmare.

2023 AF Symposium: Innovative A-Fib Ablation Plus LAA Closure in One Procedure

This report from the 2023 AF Symposium is about an innovative treatment for A-Fib patients―combining A-Fib ablation with the insertion of a Left Atrial Appendage (LAA) occlusion device in a combined procedure.

Closing off the Left Atrial Appendage has become an important topic for patients looking to be A-Fib free.

Many A-Fib stokes originate in the Left Atrial Appendage. And many recurrences of A-Fib come from the Left Atrial Appendage, too.

Inserting a Watchman occlusion device to close off the LAA has become a relatively simple and fast process. Combining it with a catheter ablation doesn’t add much time to the ablation procedure.

This treatment strategy is currently in use in many countries overseas, but isn’t yet common practice in the U.S.

Dr. Walid Saliba of the Cleveland Clinic Foundation in Cleveland, OH explained how patient selection is important in this combined procedure. To learn more read my report…

 

2023 AF Symposium: Live Case from Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter

2023 AF Symposium

Dr. Joseph Galvin, Dublin, Ireland

Live Case Presentation from Dublin, Ireland. Pulsed Field Ablation for AF Using a Multispline Catheter

The presenters of this live presentation were Drs. Joseph Galvin and Gabor Szeplaki from Mater Private Hospital in Ireland. They perform 800-900 ablations/year and have done 268 cases of Pulsed Field Ablation (PFA) using the Boston Scientific Farapulse system.

As we watched this live ablation, they used the optimized biphasic wave form for the PFA ablations. Dr. Szeplaki did the actual ablation while Dr. Galvin commented.

Dr. Gabor Szeplaki, Dublin, Ireland

No Lead Aprons

The first thing one noticed was that, instead of the typical Lead apron shields to protect against Fluoroscopy radiation, they were wearing what looked like plastic vests which were leadless. (Zero Gravity system by Biotronik.) These shields attach via a magnet to the operator who wears a vest with a magnet at the front.

66-Year-Old Female with Common Right Atrium

The patient was a 66-year-old woman who had developed symptomatic paroxysmal A-Fib three years ago. She had been taking Sotalol but tolerated it poorly. They also had tried dronedarone, but she had symptoms.

Her CHA2DS2-VASc score was 3. She had hypertension. Her left atrium was otherwise healthy. She had a somewhat unusual pulmonary vein anatomy with what looked like a huge common right ostium. They used general anesthesia rather than conscious sedation.

Ablation Procedure

NOACs (Novel Oral Anticoagulants) were discontinued the morning of the procedure.

A TEE (Transesophageal Echocardiogram) was used to make sure there was no thrombus (clot) in the heart.

They used Ultrasound to position the catheter to puncture the vein. In the heart they used a single transseptal puncture to access the left atrium. They used the Orion catheter for 3-D mapping and paced from the Coronary Sinus.

The mapping software was integrated into the Farapulse system in real time, which is a great help to the EPs. The catheter sheaths were transparent so that they could better see and eliminate bubbles on the catheters.

Farapulse catheter Open-Basket configuration

Farapulse catheter – Five Petal Flower configuration

Each vein to be ablated received four basket and four petal ablations rotating the catheter each time for better coverage. (For a more detailed description of the Farapulse system, see my 2020 report, Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.) 

They made sure that both exit and entrance block were achieved in each vein. As they ablated, the heart tissue on the screen changed from light red to dark red.

Even with the large common right ostium, they still used the 31mm catheter rather than the larger size. The patient was successfully ablated and returned to normal sinus rhythm.

Overall their results in their center are 96% vein isolation and 84% curable PVI.

Dr. Galvin commented that when they first started, PFA ablations were taking 6-7 hours. But now they are doing them in 40 minutes.

Editor's CommentsEditor’s Comments

PFA Ablation Easy, Safe and Effective: The Farapulse ablation protocol has become relatively easy and safe to do. The operators in Ireland seemed very proficient, confident, and experienced. For them this was no big deal and almost routine. This is great news for patients. 40 minutes is a very short time to perform an ablation. And with no complications.
PFA Not Yet Approved in U.S.―But Will Be Soon. PFA ablation is not yet approved in the U.S., but has been approved overseas and has been in use for some time. Panelists from Germany pointed out that PFA ablation is now done on an out-patient basis with no need to stay in a hospital overnight. This is all good news for U.S. patients with Atrial Fibrillation.
Transparent Radiation Shields Great Advance: And using these transparent shields to protect against radiation exposure is a huge advance for EPs doing ablations.

I’ve been in operating rooms and had to wear those lead aprons used today by most EPs. They are really heavy and wear you down by the end of the day. All too many EPs develop slipped disks or other back problems. And reducing or eliminating radiation exposure improves EPs health and peace of mind. Good news for EPs!

If you find any errors on this page, email us. Y Last updated: Saturday, August 12, 2023

Return to 2023 AF Symposium Reports

2023 AF Symposium: Challenging Case―Ablates Hot Spots in Low Voltage Areas

2023 AF Symposium

Dr John Day, Salt Lake City, UT

Challenging Case―Ablates Low Voltage High Frequency Areas

Dr. John Day of the Heart Center of St. Mark’s Hospital in Salt Lake City, UT presented the case of a 56-year-old young man in otherwise good health. His BMI was normal. He had had an ablation but was still in A-Fib, according to his Apple watch. “Doc, I’m still having A-Fib. You’ve got to fix it.” He had mild or moderate left atrium enlargement but no clear A-Fib triggers. He didn’t want to be on drugs. He had tried Flecainide which lowered his heart rate too much. He couldn’t exercise on Flecainide.

Dr. Day gave the audience the following choices and asked their opinion.

1. End the case [with no further treatment]

2. Change the antiarrhythmic.

3. Ablate again.

Mapping illustration: Low-voltage high frequency areas targeted for ablation

The consensus of the audience was to ablate again. And this was indeed how Dr. Day proceeded.

Second Ablation of Hot Spots

In this patient’s second ablation, all the PVs (pulmonary veins) remained isolated. A­-Fib was induced with pacing and Isoproterenol. Dr. Day used electrogram guided ablation.

When in both sinus rhythm and atrial fibrillation, the patient had low-voltage zones (suggestive of left atrial fibrosis) on the posterior wall of the left atrium.

Dr. Day targeted very high frequency signals (hot spots) appearing in low voltage areas. He remarked:

• “We only mark low voltage zones (diseased tissue) if it is low voltage in both sinus rhythm and atrial fibrillation.”
• “We only treat confirmed low voltage zones with high frequency signals…basically with this approach we are only treating diseased tissue with intense abnormal electrical activity which often corresponds to atrial fibrillation driver sites.”

Dr. Day admitted this doesn’t always work. But he has done over 5,000 ablations where this technique is effective.

The patient’s A-Fib didn’t terminate during the ablation, but it did later. Sometimes these patients have to be cardioverted to get them back into normal sinus rhythm.

This patient has been A-Fib free for 18 months and is off of Flecainide.

Editor's Comments

Editor’s Comments

Dr. Day and his colleagues may have developed a new method of making patients with difficult cases A-Fib free.

Innovation approach. Instead of looking for “potentials”, he ablates areas of low voltage and high frequency. This is an innovative approach and could help many patients with difficult cases.

If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023

Return to 2023 AF Symposium Reports

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