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


Catheter Ablation

Gastroparesis: a Rare Complication After A-Fib Ablation

Gastroparesis is a condition in which your stomach empties into your small intestine more slowly than it should. It can be either temporary or chronic. Gastroparesis can occur after surgery or another medical procedure that interrupts your digestion.

Symptoms of Gastroparesis

When you have Gastroparesis, you feel bloated after eating, you may have stomach pain, or you may be vomiting. You may lose weight, your blood sugar levels may fluctuate, you may be dehydrated, your esophagus may be inflamed and you may experience malnutrition because your stomach isn’t absorbing nutrients.

Gastroparesis After Catheter Ablation

Gastroparesis is a rare complication of A-Fib ablation. It’s a condition that affects the stomach muscles and prevents proper stomach emptying. If after your catheter ablation, you experience any of the above symptoms, you may be experiencing Gastroparesis.

The cause can be damage to the vagal nerve which controls the stomach muscles. This can happen when ablation at the right inferior Pulmonary Vein (PV) affects the esophagus. The distance between the right inferior PV (RIPV) and the esophagus is an independent predictor of gastroparesis. … Continue reading this report…->

ADVENT Trial of Pulsed Field Ablation (PFA) for Paroxysmal A-Fib! PFA a True Game Changer

Fundamentally different from traditional methods for cardiac ablation, I expect the FARAPULSE Pulsed Field Ablation (PFA) will change the way catheter ablations are done and will become an innovative and most effective treatment option for Atrial Fibrillation.

U.S. Trial of Pulsed Field Ablation (PFA)

The U.S. trial of the FARAPULSE Pulsed Field Ablation (PFA) system is underway. The first patients in the ADVENT Trial were treated at New York’s Mount Sinai Hospital by Vivek Reddy, M.D., Director of Cardiac Arrhythmia Services.

” I believe PFA will define a new era in the ablation of AF and possibly other arrhythmias.” – Dr. Pierre Jais, French Bordeaux LIRYC

The ADVENT Trial is a prospective randomized pivotal trial of the FARAPULSE Pulsed Field Ablation System compared with standard of care ablation in patients with paroxysmal atrial fibrillation.

“…We look forward to how our study can move adoption of this procedure forward,” said Dr. Vivek Y. Reddy.

ADVENT Trial is Recruiting: You May Quality

There are 37 study locations participating in the ADVENT Trial (see the list). Recruiting is underway and you may qualify.

Key inclusion criteria: Patients are required to meet all the following inclusion criteria to participate in this study (there are also exclusion criteria):

• Age 18-75
• Paroxysmal atrial fibrillation
• Anti-arrhythmic drug failed for efficacy or intolerance

Learn more about the ADVENT Trial on the FARAPULSE website. Prospective patients of The ADVENT Trial should contact their physician.

How PFA Works

As an emerging technology, there are many concepts and treatment strategies that will be brand new to you (they were for me).

Pulsed Field Ablation (PFA) is fundamentally different from traditional methods for cardiac ablation. PFA is very tissue selective.

PFA is Tissue Selective; Green labels are Preserved tissue; Red label is Ablated tissue

Through a process called irreversible electroporation, cardiac tissue targeted for ablation is rendered electrically inactive while collateral tissues are spared.

Unlike traditional thermal methods, PFA works on the selected cell types while leaving others alone.

Based on European clinical trials, these electric fields have proven very effective in durably “silencing” abnormal heart signals, while reducing the risk of damage to other nearby tissues.

For more on how PFA works, see my report: 2020 AF Symposium Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.

First Approved in Europe

In March 2021, Pulsed Field Ablation (PFA) from FARAPULSE, Inc. received CE Mark approval and can now market in the Europeans Union and other CE Mark countries. FARAPULSE plans to launch by first partnering with a select number of physicians, then move to a broader rollout.

Boston Scientific has expanded investment in FARAPULSE, Inc. and secured an exclusive option to acquire it.

Resources for this article
• Reddy VY, et ak. Pulsed Field Ablation of Paroxysmal Atrial Fibrillation: 1-Year Outcomes of IMPULSE, PEFCAT, and PEFCAT II. JACC Clin Electrophysiol. 2021 May;7(5):614-627. doi: 10.1016/j.jacep.2021.02.014. Epub 2021 Apr 28. PMID: 33933412.

• First AF Patients Treated With Farapulse Pulsed Field Ablation System. DAIC.com  MARCH 03, 2021. May-June 2021 Issue. https://www.dicardiology.com/content/first-af-patients-treated-farapulse-pulsed-field-ablation-system

• The FARAPULSE ADVENT PIVOTAL Trial (ADVENT). ClinicalTrial.gov https://www.clinicaltrials.gov/ct2/show/NCT04612244?term=NCT04612244&draw=2&rank=1

More Reports from the 2021 AF Symposium

Each year you’ll find me at the annual AF Symposium. It’s a unique experience. I attend presentations by the most eminent medical researchers, scientists, cardiologists and cardiac electrophysiologists working in A-Fib today.

I’ve published two more summary reports from the 2021 AF Symposium:

Spotlight Session: Javelin VINE Filter to Prevent Stroke

The idea behind the Javelin Medical VINE filter is to catch and stop clots (emboli) trying to travel up into the brain. This is done by inserting the VINE filter into both carotid arteries.(Of all the 5-minute Spotlight Session talks, this is my personal favorite.)

That’s incredibly good news for many A-Fib patients! It’s simple, ingenious, and very effective. Javelin Medical is an Israeli company located in Yokne’am Illit, Israel. Read more.

Live Case: Vein of Marshall Alcohol Ablation2021 AF Symposium Live Streaming Video

The AF Symposium audience watched live streaming video from Houston as Dr. Miguel Valderrabano demonstrated an innovative treatment for A-Fib using Alcohol Ablation of the Vein of Marshall.

In difficult A-Fib cases (persistent, long-term persistent), the Vein of Marshall can contain A-Fib signals (potentials, triggers) which are hard to reach and ablate. Adding ablation of the Vein of Marshall using Ethanol has been proven effective.

Using a 3 mm balloon catheter containing ethanol, he distributed ethanol into the Vein of Marshall starting distally (at the far end of the vein). Read more.

To browse through my other reports, go to 2021 AF Symposium Reports. For reports from other years go to Archive of AF Symposiums Summaries by Year

 

2021 AF Symposium Live Case: Vein of Marshall Alcohol Ablation

2021 AF Symposium

Live Case: Vein of Marshall Alcohol Ablation

by Steve S. Ryan

2021 AF Symposium Live Streaming VideoBackground: In difficult cases of A-Fib (persistent, long-standing persistent), catheter ablation has had limited success. Adding ablation of the Vein of Marshall using Ethanol has been proven effective. In the VENUS clinical trial, the ethanol infusion ablation patients had significantly improved “AF burden, freedom from AF after multiple procedures, and peri-mitral flutter block” versus the ablation-only patients.

Dr. Miguel Valderrabano

Live from Houston

The AF Symposium audience watched on live streaming video as Dr. Miguel Valderrabano of the Methodist DeBakey Heart Center in Houston, Texas, demonstrated an innovative treatment for A-Fib using Alcohol Ablation of the Vein of Marshall.

The Patient: A 69-year-old male had been in persistent A-Fib for 3 years, He had been cardioverted and was on amiodarone. He was mildly symptomatic. He came to Dr. Valderrabano in June 2020 in persistent A-Fib for at least 7 months.

When the Symposium audience first saw Dr. Valderrabano in Houston, he had already performed a standard Pulmonary Vein Isolation (PVI) of the PVs when the patient went into peri-mitral atrial Flutter. He also had worked on the posterior left atrium wall.

The Vein of Marshall

Location of Vein of Marshall

The Vein of Marshall is a vein connected to the Coronary Sinus near its opening (ostium).

In difficult A-Fib cases (persistent, long-term persistent), it can contain A-Fib signals (potentials, triggers) which are hard to reach and ablate. It’s located within the mitral isthmus.

Mapping and Diagnostic Catheter

In this live case, Carto mapping had revealed that this patient’s Vein of Marshall did have A-Fib signals.

Dr. Valderrabano had a sheath in the coronary sinus and a LIMA catheter engaged in the vein of Marshall ostium. (A LIMA catheter can be bent into various shapes.) He advanced a miniaturized octapolar Baylis diagnostic catheter (which specializes in reaching previously inaccessible areas of the heart) into the vein of Marshall.

Innovative Treatment: Ethanol Ablation

Dr. Valderrabano demonstrated an innovative ablation treatment called Ethanol Ablation.

Using a 2 mm balloon catheter containing ethanol, he distributed ethanol into the Vein of Marshall starting distally (at the far end of the vein). He would deflate the balloon and re-inflate it with ethanol to continue the ablation.

Using a 2 mm balloon catheter containing ethanol, he distributed ethanol into the Vein of Marshall. 

He stressed that the Vein of Marshall is somewhat delicate and frail.

He very gently injected the ethanol and did it in stages (distal to proximal), 1 cc over 2 minutes. He was able to achieve peri-mitral atrial flutter block by ethanol to achieve mitral Isthmus ablation. The patient’s Flutter terminated after the first ethanol injection!

He wound up doing 5 injections to cover the entire Vein of Marshall and its branches.

The ethanol basically scars (denervates) the Vein of Marshall eliminating any potentials (A-Fib signal sources or triggers).

He did this in graduated stages to make sure the ethanol didn’t affect the left atrium. He pointed out that this ablation technique done properly is safe.

Editor’s Comments

Ethanol Ablation Difficult to Perform: This is the first time I had seen an Ethanol Ablation. It’s obviously not the easiest procedure to perform.
In the VENUS trial, 30 of 185 patients weren’t able to achieve ethanol ablation, even though the operators and A-Fib centers involved were some of the best in the world.
Ethanol Ablation—Potential Breakthrough Treatment! When you consider how difficult it often is to cure more challenging cases of A-Fib (persistent and long-standing persistent), Ethanol ablation as demonstrated by Dr. Valderrabano is a major breakthrough!
EPs now have a way to ablate previously inaccessible areas of the heart!
All too often before this, some patients with persistent/long-standing persistent A-Fib could not be cured and had to resign themselves to live with A-Fib for the rest of their lives.

Now there is hope for even the most difficult A-Fib cases. We may have reached a beginning stage in A-Fib research where no one has to live permanently in A-Fib!

Resources for this article

• Valderrabano, M et al. Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation― The VENUS Randomized Clinical Trial. JAMA. 2020;324(16):1620-1628. doi:10.1001/jama.2020.16195 https://tinyurl.com/VENUS-Clinical-Trial

• Virtual ACC: Ethanol infusion in vein of Marshall improves catheter ablation outcomes. Cardiac Rhythm News, March 29, 2020. https://tinyurl.com/Ethanol-Infusion

If you find any errors on this page, email us. Y Last updated: Tuesday, June 8, 2021

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Catheter Ablation for A-Fib Lowers Dementia Risk

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 a link between patients with Atrial Fibrillation and an increased risk of dementia.

Normal Sinus Rhythm Reduces Dementia Risk

Successful ablation for A-Fib linked with reduced risk of dementia.

Using data from South Korea’s National Health Insurance Service, researchers identified 9,119 patients with Atrial Fibrillation who had a catheter ablation and 17,978 who received medical therapies.

During the follow-up period (6-12 years) dementia was found in 164 cases 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.

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.

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…” (But not if the ablation failed.)

Editor’s Comments
Editor's Comments about Cecelia's A-Fib storyImproved 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!

Resources for this article
Catheter ablation linked to lower incidence of dementia in AF patients. Cardiac Rhythm News. October 7, 2020. https://tinyurl.com/86mnkas2

Q&A: Can Catheter Ablation Be a First-Choice Option?

Q: “I was told that I can’t have a catheter ablation to fix my A-Fib until after at least a year of trying different medications. Is that right? I don’t want to live in A-Fib for a year. I’m very symptomatic. I hate being in A-Fib.”

A: Catheter Ablation Can Be a First-Choice Option. Current Guideline for the Management of Patients with Atrial Fibrillation say you don’t have to wait before getting a catheter ablation. You can have a catheter ablation right away as a first-choice option.

Here is the actual wording of the guidelines:

“The role of catheter ablation as first-line therapy, prior to a trial of a Class I or III antiarrhythmic agent, is an appropriate indication for catheter ablation of AF in patients with symptomatic paroxysmal or persistent AF.”

Guidelines Level of Confidence: Catheter Ablation has a Class IIa Level of Evidence (LOE) indication. This means the “weight of evidence” is in favor of this treatment as useful and effective. (To read more, see Catheter Ablation of AF as First-Line Therapy (p. e307.), in the 2017 HRS/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.)

Drugs First? Your doctor may talk about first trying antiarrhythmic meds. This can waste valuable time as most “antiarrhythmic” drug therapies are only effective about 40% of the time, can have bad side effects, and often become less effective day by day. And, you will most likely still have A-Fib.

Catheter Ablation as a First Choice? If you want to skip the drug therapies, ask your doctor about catheter ablation. If your electrophysiologist won’t talk to you about catheter ablation, seek a second opinion (or change doctors).

As an A-Fib patient, know your rights and be assertive.

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

EARLY-AF is a Canadian study of CyroBalloon ablation by lead author Dr. Jason Andrade of the University of British Columbia Faculty of Medicine and colleagues. According to study researchers, CryoBalloon ablation “is a more effective first-line treatment for (A-Fib) patients than medication.” (The full name of the EARLY-AF study is “Early Aggressive Invasive Intervention for Atrial Fibrillation”.)

Cryoballoon ablation 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 (Medtronic Arctic Front Advance), while the other half were treated with antiarrhythmic drugs (AADs)(flecainide, sotalol, propafenone, or dronedarone). (Flecainide was the most frequently prescribed.) All patients received an implantable loop recorder (Medtronic Reveal LINQ) which allowed for continuous monitoring and the assessment of atrial fibrillation burden. .

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 and your A-Fib has gotten worse (remodeling).
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. https://www.med.ubc.ca/news/a-procedure-not-medication-may-be-a-more-effective-first-line-of-treatment-for-common-heart-rhythm-problem/

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

• Andrade, J. et al. Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation. The New England Journal of Medicine, January 28, 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2029980. DOI: 10.1056/NEJMoa2029980.

f you find any errors on this page, email us. Y Last updated: Monday, May 31, 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. https://www.ahajournals.org/doi/10.1161/CIRCEP.120.008718

• 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. https://cardiacrhythmnews.com/catheter-ablation-may-be-up-to-10-times-more-effective-than-drug-therapy-alone-at-delaying-af-progression/

A-Fib is Progressive infographic at A-Fib.com

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