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

AVNRT Diagnosed, 2nd Ablation—Finally A-Fib Free

Prior to 2015, I was an active 67-year old male who had taken up running in my late 30’s…I had never experienced any heart issues. Late in September 2015, my heart was racing and a local Spokane hospital ER informed I was experiencing atrial fibrillation. Approximately 12 hours later, with meds, I was back in normal sinus rhythm.

Bob Thompson, Spokane, WA

Over Three Years A-Fib, Bouts Become More Frequent

Over the next few years, I went into A-Fib over 50 times with each bout lasting on the average 10 to 12 hours.Taking metoprolol while in A-Fib, got me back in normal sinus rhythm. I never needed to have a cardioversion.

After dealing with A-Fib for over three years and with the occurrences becoming more frequent, I opted to have a heart catheter ablation in September 2018. Result: the ablation was a complete failure. The EP was only able to ablate three of the four pulmonary veins.

Ablation Fails—Exploring Mini-Maze Procedure

After my failed ablation, my occurrences of A-Fib rapidly increased. I began to explore another option, a mini-maze procedure.

The cardiac surgeon in Spokane suggested I try one more catheter ablation before I opted for the mini-maze procedure.

I met with a cardiac surgeon in Spokane who suggested I try one more catheter ablation before I opted for the mini-maze procedure. The surgeon informed me that the best EP in Spokane was Dr. Mark Harwood whom he would be seeing later in the day.

Best EP in Spokane Calls Me the Next Day!

One day after meeting with the cardiac surgeon, I received a call from Dr. Harwood’s office. Upon meeting with Dr. Harwood, he informed me that he was confident of his ability to ablate all four of my pulmonary veins.

Scheduled for Ablation But Stress Test Reveals AVNRT

I was scheduled to have my second ablation in March 2019, but it was contingent on the results of a stress test.

A few days later, at the end of the stress test, I went into A-Fib. An irregularity (tachycardia) was detected requiring an AVNRT Ablation as well. Continue reading Bob’s story…->

A Failed Ablation, then AVNRT Diagnosed and 2nd Ablation—Now Finally A-Fib Free

Bob Thompson, Spokane, WA

By Bob Thompson, Spokane, WA, August 3, 2020

Prior to 2015, I was an active 67-year old male who had taken up running in my late 30’s. I had been diagnosed with Essential Tremor [involuntary shaking or trembling] early in my life but otherwise was considered to be very healthy. I had never experienced any heart issues. Little did I know how much my life was about to change.

Late in the evening of July 11, 2015, I began to feel like my heart was racing and immediately went to a local Spokane hospital ER. After a short period of time, I was informed that my heart was experiencing atrial fibrillation.

Since I was already taking the beta blocker metoprolol for my Essential Tremor, the ER staff intravenously gave me some additional metoprolol. Approximately 12 hours later, I was back in normal sinus rhythm.

Surprised by A-Fib―Researching on the Internet

But what was atrial fibrillation? I had never heard of this diagnosis before the summer of 2015. As is my custom when I am unfamiliar with something, I went to the internet and began to research A-Fib.

I discovered Steve Ryan’s website, A-Fib.com and almost immediately ordered a copy of his book, Beat Your A-Fib.  Both Steve’s website and book have been invaluable resources in my quest to deal with my A-Fib.

A-Fib Attacks Continue Lasting 10-12 Hours―Tries Drug Therapy

Over the next few years, I went into A-Fib over 50 times with each bout lasting on the average 10 to 12 hours. Increasing my dosage of metoprolol while in A-Fib, resulted in being able to get back into normal sinus rhythm, and I never needed to have a cardioversion.

I found the drug fecainide (the so-called Pill-in-the-Pocket treatment) did nothing but cause extreme stomach discomfort.

My first electrophysiologist (EP) recommended that I take flecainide whenever I went into A-Fib (the so-called Pill-in-the-Pocket treatment), but I found that particular drug did nothing but cause extreme stomach discomfort.

The EP also recommended I try some additional drugs such as sotalol and amiodarone, but I resisted because of the likely side effects that would result. I did, however, agree to take the blood thinner Eliquis.

After Three Years, Time for a Catheter Ablation―Disappointing Failure

After dealing with A-Fib for over three years and with the occurrences becoming more frequent, I opted to have a heart catheter ablation on September 15, 2018.

Result: the ablation was a complete failure. The EP was only able to ablate three of the four pulmonary veins.

Rather than a Mini-Maze, the surgeon suggested another ablation and referred me to the best EP in town.

A-Fib Occurrences Increase, Exploring Mini-Maze Procedure

Subsequent to the ablation, my occurrences of A-Fib rapidly increased. I began to explore another option, a mini-maze procedure. I met with a cardiac surgeon in Spokane who suggested I try one more catheter ablation before I opted for the mini-maze procedure.

The surgeon informed me that the best EP in Spokane was Dr. Mark Harwood whom he would be seeing later in the day. I informed the surgeon I was aware of Dr. Harwood’s reputation, but I was never able to see him because the EP who had performed the first ablation was part of the same practice of EPs.

Dr. Harwood’s Office Calls Me the Next Day!

One day after meeting with the cardiac surgeon, I received a call from Dr. Harwood’s office informing me that Dr. Harwood could see me the next day. Upon meeting with Dr. Harwood, he informed me that he was confident of his ability to ablate all four of my pulmonary veins.

AVNRT stands for Atrioventricular Node Reentrant Tachycardia.
I was scheduled to have my second ablation with Dr. Harwood on March 15, 2019, but it was contingent on the results of a stress test. A few days later, the stress test was performed and was a success.

However at the completion of the stress test, I went into A-Fib. Dr. Harwood detected an irregularity (Tachycardia) that lead him to also perform an AVNRT Ablation.

Another Ablation in March 2019

As scheduled, I had an atrial fibrillation ablation on March 15, 2019. Unlike my first ablation, Dr. Harwood was able to successfully ablate all four pulmonary veins.

In addition, at the same time, Dr. Harwood also performed an AVNRT (Atrioventricular Node Reentrant Tachycardia) ablation which he felt was needed after detecting an irregularity in the EKG during the earlier stress test. [For more about AVNRT, see my Editor’s Comments below.]

After almost four years, I am A-Fib free; I and my wife now have our lives back.

Success! A-Fib Free Since March 2019

Subsequent to my 2019 ablation procedures, I have had no recurrences of A-Fib. I no longer need to take the blood thinner Eliquis.

In other words, after almost four years, I am A-Fib free, and I and my wife now have our lives back.

Lessons Learned: My Advice

Lessons learned about life with A-Fib

Here is my advice to others who are battling A-Fib:

1. Never give up in trying to find a cure for this insidious disease. Do not accept the words “Learn to Live with It”.

2. Do not settle for seeing the first available EP which is a mistake I made. Talk to other physicians and medical professionals and ask them for recommendations.

3. It is normal to have anxiety when dealing with A-Fib. My digestive system was a complete mess until I was finally convinced to take some anxiety medication.

4. Try to avoid being tired. Looking back at the chart I kept for my A-Fib incidences shows a definite pattern of going into A-Fib after excessive exercise or work.

5. If you have doubts as to whether or not you are experiencing A-Fib, go to a local fire station that has a paramedic on site. You will be able to have an EKG at no cost.

VIDEO: Learn how your heart works, see  Your Heart’s Electrical System:An Introduction.

In Gratitude

In conclusion, I will be forever grateful to Dr. Mark Harwood of Providence Spokane Cardiology-North, for going beyond the parameters of a normal ablation of the pulmonary veins and performing the AVNRT ablation which likely resulted in my cure.

In addition, I am so thankful for the input I have received from Steve Ryan from his website and book as well as one-on-one correspondence.

You can contact me at easychatt@aol.com.

Bob Thompson
Spokane, WA

Editor’s Comments

Editor's Comments about Cecelia's A-Fib story

All EPs Are Not Equal: It’s a shame that Bob’s first EP wasn’t able to isolate all of his PVs. Unfortunately, all EPs are not equal. One of the hardest tasks A-Fib patients face is finding the right EP.
Don’t be afraid to get a second (or third) opinion. Don’t just go with an EP who happens to work near you. Be prepared to travel. Go to the best, most experienced EP you can find, afford, and to where you can reasonably travel.

Search Out the Best EP You Can Find: One of the best ways to find a good EP is what Bob did: talk to doctors, nurses, or support staff who work in the field. They can often tell you who is the best and whom to avoid. But getting this kind of inside info isn’t easy and isn’t possible in many cases.

How Do You Find the Right EP for You? To learn how electrophysiologists differ and how to find the right EP for you, see two of my articles:

A Tale of Two Ablations and Why All EPs Are Not Equal
Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.

Bob’s Persistence: What’s inspiring about Bob’s story is his persistence in getting to the best EP in Spokane. God bless the wonderful surgeon who recommended that Bob see Dr. Harwood, even though that surgeon might lose a patient for his own Mini-Maze surgery.

Heart in AVNRT: Instead of a single path, an extra (re-entry]) circuit is shown from the Sinus node and within the AV node.

Technical Description of Bob’s Ablation

Kudos to Dr. Harwood for discovering that Bob had AVNRT and an extra circuit (from the Sinus node and within the AV Node).The ablation for ANVRT is a somewhat unusual procedure.
AVNRT stands for Atrioventricular Node Reentrant Tachycardia.
Normally, the AV Node electrically connects the atria and ventricles and is normally a single electrical road. But in AVNRT, there is a re-entry [extra] circuit within or adjacent to the AV Node.
Catheter Ablation of Pulmonary Veins
Bob’s Left Superior Pulmonary Vein [RSVP] needed to be ablated at the roof, and the Left Inferior Pulmonary Vein [LIPV] needed to be ablated at the ridge.
After isolating Bob’s PVs, Dr. Harwood administered adenosine to confirm entrance and exit block. He then waited 30 minutes to re-confirm that all PVs remained blocked/isolated.

AVNRT illustration: The extra path creates cardiac conduction with both a Fast signal and a Slow signal that disrupts normal sinus rhythm.

Ablation for AVNRT
Next Dr. Harwood used atrial pacing on isoproterenol to induce Supraventricular Tachycardia [SVT].
Then he ablated this extra pathway or circuit which eliminated Bob’s re-entrant tachycardia without damaging Bob’s normal AV Node circuit/pathway.
In effect, he found and engaged Bob’s “Slow Pathway” circuit which was adjacent to his normal AV Node circuit.

After 50 years of Irregular Heartbeats and PVCs, Finally an A-Fib Diagnosis and Treatment

Cecelia Hender, 72, shares about her life with Atrial Fibrillation. She writes that heart arrhythmias have been a part of her life since she was a young woman.

I was about 20 years old when I first experienced irregular heartbeats. My doctor back then told me it was “nerves” and to relax.

This was how most women were treated by doctors back then. Everything was “nerves”.

Cecelia Hender from Abington, MA with her granddaughter.

In my 30’s, I told another doctor how my heart would take off like a race horse, I could not breathe. He said, “try not to think about it.”  What????

I fought with these irregular heartbeats for many years. I was never told to see a cardiologist or have a doctor investigate just what was going on.

Sent to a Cardiologist Almost By Accident

About 15 years ago, I worked for a medical facility, and one day a young doctor came in and was waiting for an interview…when he said he was an electrophysiologist [cardiac specialist], I asked about my irregular heartbeats.

He was so kind and intelligent…It was this young doctor who told me that I should see a cardiologist. So, I did. And I was treated with medications and wore many heart monitors.

Hard to Document the Arrhythmia

But it was always hard to catch the arrhythmias on an ECG or heart monitor.

My whole life was spent afraid and never going anywhere alone for fear that my heart would act up and I’d be stranded someplace unable to breathe – unable to move. 

Finally, in 2017 I had another [heart] monitor, and it showed a series of irregular heartbeats.

But on this one particular day, I had a very irritating rhythm. It was very fast, then irregularly fast, and I could barely breathe. I went to my PCP [Primary Care Physician] office where they did an EKG and said, “You are in A-Fib”.

They sent me immediately to my cardiologist who confirmed this. I was put on a different kind of med (Metoprolol at first and also Coumadin). And “fingers crossed” I would convert on my own. It took almost two weeks…Continue to read how two ablations brought Cecelia Hender relief from A-Fib and PVCs, and about a recent setback ->

“Your A-Fib is Just Nerves”…”Try Not to Think About It”; At 72 Finally A-Fib & PVCs-Free After 2 Ablations, But Then a Setback

By Cecelia Hender, July 2020

Cecelia Hender and granddaughter

I have been asked to write my story about my journey with A-Fib. I have had arrhythmias since I was a young woman. I was about 20 years old when I first experienced irregular heartbeats. I had gone to my doctor back then and was told it was “nerves” and to relax. This was how most women were treated by doctors back then. Everything was “nerves”.

Time passed, and the irregular heartbeats seemed to get worse at times.

In my 30’s, I remember going to another doctor and told him that when my heart would take off like a race horse, I could not breathe. And when it stopped, I felt I could climb a mountain again. He said, “try not to think about it.”  What ????

I fought with these irregular heartbeats for many years. I was on different blood pressure meds that also helped with heartbeats, but I was never told to see a cardiologist or have a doctor investigate just what was going on.

Once or twice, when I was younger, a doctor had me wear a heart monitor. It was a 24-hour monitor. And when it showed nothing for that period of time, he said I was fine.

Sent to a Cardiologist Almost By Accident―Hard to Document the Arrhythmia

I worked for a medical facility, and one day about 15 years ago a young doctor came in for an interview. He sat in my office for a good amount of time while they were preparing for the interview. During this time, I got to talk to him a lot.

When he said he was an electrophysiologist [cardiac specialist], I asked about my irregular heartbeats. He was so kind and intelligent and gave me a lot of information to think about.

It was this young doctor who told me that I should see a cardiologist. So, I did. And I was treated with medications and had many heart monitors.

But it was always hard to catch the arrhythmias on an ECG or heart monitor.

“You are in A-Fib”―Two Weeks of A-Fib Hell…

Finally, in 2017 I had another [heart] monitor, and it showed a series of irregular heartbeats.

But on this one particular day, I had a very irritating rhythm. It was very fast, then irregularly fast, and I could barely breathe. I went to my PCP [Primary Care Physician] office where they did an EKG and said, “You are in A-Fib”.

They sent me immediately to my cardiologist who confirmed this. I was put on a different kind of med (Metoprolol at first and also Coumadin). And “fingers crossed” I would convert on my own. 

I remember like it was yesterday, the moment my heart decided to go back into normal sinus rhythm. I was so happy and felt so strong…

…Then Blessed ‘Normal Sinus Rhythm!’

It took almost two weeks, but I remember like it was yesterday, the moment my heart decided to go back into normal sinus rhythm.

The feeling was like a major blessing had just descended on me. I was so happy and felt so strong in that very moment. I cried.

Dr. Seth McClennen―Successful Ablation! But PVCs Major Issue

I met with Dr. Seth McClennen, an Electrophysiologist, who decided I was a good candidate for ablation. I was so thrilled.

Finally, someone was going to help me be normal!

My whole life was spent afraid and never going anywhere alone for fear that my heart would act up and I’d be stranded someplace unable to breathe – unable to move. Finally, I found some help.

Dr. Seth McClennen is a well-known and most beloved Electrophysiologist here in the Boston area. He is the best in my book.

He told me all that I needed to know about ablation, and off I went for my very first A-Fib ablation in June 2017.

Although PVC’s don’t carry the risk of stroke as A-Fib but are just as debilitating.

It was successful! I went almost two years without an episode of A-Fib at all whatsoever.

However, my PVC’s were a major issue.  They still kept me house-bound for the most part. Afraid to go anywhere alone. Although PVC’s don’t carry the risk of stroke that A-Fib has, they were just as debilitating.

A Second Ablation for PVCs―Without General Anesthesia―No Big Deal

Dr. McClennen suggested a second ablation for the PVC’s in January 2019.  He said that it would be best if I could go through this without anesthesia, because with sedation, the PVC’s would “hide,” and the ablation would be difficult.

So, I did it … my trust in Dr. McClennen and his wonderful team outweighed any fear or apprehension on my part.

For another patient’s story about treating PVCs, see PVC-Free After Successful Ablation at Mayo Clinic by Dr. Mulpuru

My second ablation was in April 2019. The ablation without sedation was no big deal at all. Now I am talking about a PVC ablation. Seth McClennen was right there working, and I could talk to him any time. He kept me informed as to what was going on.

At one point he said, “Think of something that irritates you so we can get these to come out, and I can follow the path.”  So something that irritates me or causes stress will bring these out …. Well, it worked, and he was able to ablate these PVC’s.

Successful PVCs Ablation―Living Without Fear

For the first time in my whole life, I was able to move about without fear.

I could go to the store and feel normal—I was not worried that my heart would go crazy and I would be left in a puddle somewhere with no one to help me.

(Being a widow, it is very hard to continue life alone especially where your health is concerned. My husband died eight years ago when he was only 60 years old. I have never recovered.)

A Setback: Respiratory Infection Triggers A-Fib

Life was good as far as my heart was concerned. For three months I had no A-Fib or PVC’s. Then suddenly in April 2019, I got an upper respiratory infection which kicked off an episode of A-Fib. Oh no!!!…This familiar awful feeling was something I remembered.

It woke me up, and I immediately took my heart rate. It was 198. No one to take me to the hospital. And with my nerves, I did not want to call an ambulance. That was a BIG MISTAKE. I won’t do that again….

Anyway, a few hours later, my cousin came and took me to the Emergency Room.

They tried Cardioversion TWICE, but it did not work; so, I was put on the antiarrhythmic Tikosyn (dofetilide).

Tikosyn Works, But “Can I Have Another Ablation?”

I had to stay in the hospital for a week to level out and make sure this antiarrhythmic would be okay for me. It got my heart in perfect order, but I don’t want to stay on this forever.

So, my next question for my wonderful Dr. McClennen was “Can I have another ablation”? He answered, “Yes, we will discuss it in the Fall.”

Is Another Ablation on the Horizon?

So, I am waiting eagerly for Fall 2020 when we can discuss another A-Fib ablation. In the mean time, let me share what I’ve learned so far about treating Atrial Fibrillation.

Lessons Learned

Lessons learned about life with A-FibAblation is a Blessing and Low Risk―Better Than Living in Fear

Why do I feel excited about ablation? I truly feel that having an ablation is a blessing. And this is why I am writing this story for you.

I know there are risks and I know people are afraid of ablations, but the risks are nothing compared to living each moment of your life afraid to live.

Find a Great Doctor!

The trick is finding a great doctor. Not just a good doctor, but a great doctor.  What makes a great doctor?  Well, to ME … it’s someone who listened to me. Dr. Seth McClennen listened. He cared.  He even wants me to email him when I have a concern or question. He always answers me. Always.

Kardia Device a Great Help

AliveCor with tablet at A-Fib.com

Using Kardia with tablet; under $100.

I have a Kardia machine – it’s that little EKG tag that you can email to your doctor.  I have sent Dr. McClennen my EKG when I’ve had a question. More so now, with this antiarrhythmic drug, I am always tempted to take an EKG and send it to say “How am I doing?”  Some days I just need to know my heart is in good order.

Find a Great Pharmacist As Well

It helps greatly to have a wonderful pharmacist too. Someone you can confide in and who will help you. The particular drug I am on interacts with so many things that I have to check everything with the pharmacist. Lisa Cohen Szumita is a wonderful pharmacist who is there to answer all my questions.

So, my advice is to have a great doctor – and a wonderful Pharmacist who has that rare quality these days of “Caring” for their patients.

Your Attitude is Your Greatest Weapon

As far as ablations go…your attitude is your greatest weapon.

If you are told you need an ablation, be blessed. Be thankful and blessed.

It’s what we AFIBBERS have to help us live a normal life. Thanks be to God!  When you are going to have your ablation, go into that hospital thanking God and asking Him and His angels to surround you.

Are you in need of prayer? Positive thoughts? Read about our A-Fib Positive Thoughts/Prayer Group and how to send us your request.

Ask all of us here on the A-Fib.com website to hold you in prayer and good thoughts. That is what we are called to do.

Leave fear behind you – don’t bring fear into your procedure. Bring FAITH and JOY and PEACE. I went into that A-Fib ablation with such excitement—to finally live a life where I was not afraid to be in the store alone. A simple thing … but I was unable to do it. After ablation, my life was restored.

I was so very upset that an upper respiratory infection brought me down. But I am on the right track again. So for the time being, I will take this antiarrhythmic.  (Please don’t send me any scary emails about what I take.)  I’ve heard it all. I did all the reports at work that had any and all of these drugs listed. I know all about it. But for now, it’s what I have to do

When the Fall comes, if my cardiologist says I’m good for another ablation …. Well, thanks be to God !! …. And so it is.

P.S. I’ll update my story when I have something to share. If you want to write me, send an email to Steve and he will forward it.

Cecelia Hender
Abington, Massachusetts

Editor's Comments about Cecelia's A-Fib story

Editor’s Comments

I can’t help but get angry reading Cecelia’s story. After repeated heart rhythm complaints to her doctors, I can’t believe she wasn’t referred to a cardiologist.

She’s not alone with doctors dismissing women’s symptoms.

Other female patients have reported being told: “You’re experiencing a type of panic disorder.” “You’re exaggerating.” “A-Fib is no big deal.” “Take a Valium.” “Just take your meds and get used to being in A-Fib.”

Consequences of Gender Bias: If you are female, be prepared to experience gender bias in the medical field (but less so among Electrophysiologists [EPs]).

Beware of condescending behavior. You don’t have to accept or put up with that kind of attitude. Anticipate gender bias! Don’t let it deter you! (For more see: Women with A-Fib: Mother Nature and Gender Bias—Or—Get Thee to an EP ASAP.) 

Don’t Just Live with A-Fib: Educate Yourself! Cecelia had irregular heartbeats for decades before she learned she should consult a specialist, a Cardiologist (an electrophysiologist to be exact). 

Don’t be afraid to get a second opinion. Don’t be afraid to fire your doctor.

Thankfully Cecelia finally got her Atrial Fibrillation diagnosed. She then found one of the best electrophysiologists (EP) in her area. She learned about A-Fib. She got the best and most up-to-date advice and treatment. She had lived in fear of her A-Fib but found her cure in spite of her fears.

Catching the Arrhythmias: Cecelia describes very well her frustration when doctors tried and failed to document her A-Fib. All too often when you have occasional (paroxysmal) A-Fib, you’ll be in the doctor’s office and your heart is in normal sinus rhythm (NSR). If you’re not in A-Fib, they can’t document it with an ECG. Frustrating!

(I remember spending all morning in a doctor’s office waiting for an A-Fib attack so that an EKG can document it. But no luck. Then when I went downstairs for lunch, that‘s when I had an A-Fib episode.)

iRhythm Zio patch

Advancements in Heart Monitoring. Today doctors have any number of monitoring and data recording devices to “catch” A-Fib episodes.There are patches such as a Zio Patch which looks like a big Band Aid and which you wear for 1 or 2 weeks.

Medtronic Reveal LINQ insertable heart monitor

Medtronic Reveal LINQ

Another is an implantable loop recorder like the Medtronic Reveal LINQ which is inserted under your skin in a very simple, fast procedure. (I’ve had one for the last 1 1/2 years). It lasts for three years and tells doctors (and you) what’s going on in your heart 24/7.

Today your doctors are much more likely to “catch” and document your irregular heartbeats.

Dealing with PVCs: We’re most grateful to Cecelia for describing how Dr. McClennen fixed her PVCs which are a major issue for some people with A-Fib.

Maybe the key to ablating PVCs is no sedation or conscious sedation rather than general anesthesia. (I’ll try to get more info on Dr. McClennen’s methods of ablating PVCs.)

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Friday, October 16, 2020

Back to top

 

2020 AF Symposium: Terminate Persistent A-Fib by Ablating Higher Frequency Modulation Areas

2020 AF Symposium

Terminate Persistent A-Fib by Ablating Higher Frequency Modulation Areas

by Steve S. Ryan

Background: Previous studies by Dr. Jose Jalife, University of Michigan, Ann Arbor, MI.:
• A-Fib Produces Fibrosis—Experimental and Real-World Data: Dr. Jose Jalife’s ground-breaking research studies with sheep demonstrated conclusively that A-Fib produces fibrosis;
Experiments in Atrial Remodeling in Sheep and the Transition From Paroxysmal to Persistent A-Fib: Dr. Jalife’s later research showed how A-Fib progresses in time from paroxysmal to persistent A-Fib.

Jose Jalife MD

At this year’s AF symposium, Dr. Jalife presented findings by research colleagues showing how leading-driver regions of A-Fib have higher frequency modulation (iFM) areas which, when ablated, usually terminate persistent A-Fib.

His presentation was entitled “Using Instantaneous Amplitude and Frequency Modulation to Detect the Footprint of Stable Driver Regions as Targets for Ablation of Persistent AF.” Dr. Jose Jalife, University of Michigan, Ann Arbor, MI.

Clinical Study

Researchers have used sheep and pigs in previous studies. This time to detect rotors in sheep, researchers developed algorithms based on amplitude modulation (iAM) and frequency modulation (iFM).

They then switched to pigs who underwent high-rate atrial pacing to develop persistent A-Fib.

Frequency modulation (iFM) /instantaneous amplitude modulation (iAM) approach to patients with persistent atrial fibrillation

Using the PentaRay Catheter (Biosense Webster) to produce high-density electroanatomical atrial mapping, they found that regions of higher than surrounding average iFM were considered leading-drivers.

These iFM areas also had the highest dominant frequency. “They are the footprints of rotors.”

Not all rotors are drivers. Only those with the highest frequency and greater stability are A-Fib drivers. “IFM helps identify the regions with the highest frequency drivers.”

Researchers constructed two leading-driver + rotational-footprint maps (rotors) 2.6 hours apart from each other to test for stability and to guide ablation. Leading-driver regions remained in approximately the same spots in each map.

The trial showed high iFM areas are responsible for maintaining persistent A-Fib

Study Results

When these areas were ablated, persistent A-Fib terminated in 12 of the 13 cases (92.3%). Rotational-footprints (rotors) were found at every leading-driver region, but not all rotors had higher iFM. “In pigs, ablation of leading-driver regions usually terminates persistent A-Fib and prevents its sustainability.”

Conclusion

Dr. Jalife concluded that high iFM areas are responsible for maintaining persistent A-Fib. And using iFM results in higher sensitivity and specificity without the need for high resolution and costly panoramic mapping.

Editor’s Comments:

(I had never heard of the term “frequency modulation” (iFM) applied to A-Fib before.)
High Areas of iFM a New Discovery in A-Fib: The researchers have re-defined the field of mapping and catheter ablation.
This research shows that higher regions of iFM help identify the regions with the highest frequency drivers (rotors) and are more easily mapped in persistent A-Fib.

Dr. Jalife and his colleagues have given EPs and researchers a new tool to better ablate persistent A-Fib, the most difficult arrhythmia to fix.

Resource and Footnote
Dr. Jalife added: “The work I described in my presentation was not mine, but the result of a team effort led by a young Spanish physician and scientist named David Filgueiras Rama. David trained with me a few years ago but now has his own independent laboratory at the National Cardiovascular Research Center (CNIC) in Madrid, Spain. The idea of using iFM modulation to localize drivers was an inspiration of Jorge Quintanilla who is the first author in the paper you have cited. Together, Jorge and David generated the hypothesis, designed the experiments and wrote the paper. My roll was primarily advisory, and I helped with the final draft of the manuscript. Thus, I was only acting as a messenger at the AF Symposium.

Quintanilla, JG et al. Instantaneous Amplitude and Frequency Modulations Detect the Footprint of Rotational Activity and Reveal Stable Driver Regions as Targets for Persistent Atrial Fibrillation Ablation.  Circ Res. 2019 August6 30; 125(6):609-627. Epub 2019 Aug 1. https://www.ncbi.nlm.nih.gov/pubmed/31366278  doi: 10.1161/CIRCRESAHA.119.314930.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

Return to 2020 AF Symposium Reports

New FAQ: What is Atypical Flutter?

“I have Atrial Flutter that my EP describes as “atypical”. What does that mean? Is it treated differently than typical Flutter? (I’ve had two ablations, many cardioversions, and a Watchman installed to close off my LAA.)”

Atrial Flutter is similar but different from Atrial Fibrillation. Atrial Flutter is characterized by rapid, organized contractions of individual heart muscle fibers (see graphic below).

In general, there are two types of Atrial Flutter:

• Typical Flutter (from the right atrium)
• Atypical Flutter (can come from anywhere)

Typical Flutter originates in the right atrium (whereas A-Fib usually comes from the left atrium).

Atypical Flutter can come from anywhere and is one of the most difficult arrhythmias to map and ablate.

To learn more, read my full answer, go to: I have Atrial Flutter that my EP describes as “atypical”. What does that mean?”

A-Flutter usually comes from the right atrium (A-Fib usually comes from the left atrium).

2020 AF Symposium: Protecting the Esophagus by Cooling It

2020 AF Symposium

Protecting the Esophagus by Cooling It

Mark Gallagher. MD

“We know that most strategies (to prevent fistula) don’t work,” Says Dr. Mark Gallagher from St. George’s University Hospital in London, United Kingdom.

At the 2020 AF Symposium, he described an innovative strategy he and his colleagues developed to prevent fistula. He presented the completed IMPACT study which investigated whether Attune Medical’s ensoETM esophageal cooling system could effectively reduce the incidence and severity of thermal injuries to the esophagus during cardiac ablation.

What is Atrial Esophageal Fistula?
Atrial-Esophageal Fistula is the worst complication of a catheter ablation. Unlike most other ablation complications, this can kill you.

What is Atrial Esophageal Fistula? During an ablation, heat from the RF catheter applied to the back of the heart can damage the esophagus which often lies just behind the posterior wall of the left atrium. (This can also happen to some extent with Cryo ablation.)

How Atrial Esophageal Fistula can kill You: If RF heat damages the esophagus, ulcer-like lesions form in the esophagus. Then 2-3 weeks post-ablation, gastric acids (reflux) can eat away at these lesions creating a fistula (hole) from the esophagus into the heart. Without major intervention, blood can pump from the heart into the esophagus leading to death.

IMPACT Double Blind Randomised Controlled Trial

In their clinical trial, Dr. Mark Gallagher and colleagues divided 120 patients into two groups: a control group and a experimental group.

IMPACT stands for Improving Oesophageal Protection During Catheter Ablation for Atrial Fibrillation.

The Control Group: The control group received only standard care, in this case a temperature probe in the esophagus. If the temperature in the esophagus went too high, they would stop the ablation till the temperature went back down (current practice).

This would often lead to the EP not being able to effectively isolate all A-Fib signal areas in the heart which were too close to the esophagus. And often, by the time the temperature went up, damage had already been done to the esophagus.

The Experimental Group: Patients in the second (experimental) group instead received a 3-foot long silicone soft tube in their esophagus connected to what was basically a refrigerator. This closed loop system pumped cooled water (25  ͦ F) down one loop of the tube, then back through another loop to the console whenever the EP worked near the esophagus. The EP controls the temperature.

Double-Blind for Both Operators and Evaluators

This was a double-blind study. The EP doing the ablation didn’t know if they were working on a Control or Experimental patient. And the doctors evaluating the procedure for possible esophagus damage also were blinded.

After 7 days, an endoscopy was performed on each patient’s esophagus (an endoscopy examines the inside of an organ). They were looking for lesions and for gastroparesis (delayed emptying of the stomach).

IMPACT Study Results

The Control group who received the standard temperature probe had multiple epithelial lesions, while the Experimental group who experienced the closed loop cooling system had only one minor lesion.

The Experimental group also needed less fluoroscopy (X-ray) time. And, more importantly, the EP was able to ablate longer in areas near the esophagus (such as the posterior wall of the left atrium). That improved the success rate of the ablation and ablation efficacy.

Editor’s Comments

Most fistula patients die. And for those who live through the emergency treatment, they are often compromised for life. But with the esophageal cooling system, patients and doctors may never again have to worry about the dreaded complication Atrial-Esophageal Fistula!
Cooling the Esophagus, a Major Medical Breakthrough! Cooling the esophagus is simple and relatively easy to do. And, barring future research findings, it seems full proof.
The Attune Medical’s ensoETM esophageal cooling system is certainly cheaper than having to care for patients with a fistula.
The Attune Medical ensoETM esophageal cooling system can provide both cooling during RF ablation, and heating during Cryo ablation.
Probably among the major proponents of the esophagus cooling system will be hospital administrators. Treating patients with a fistula is a huge expense and a nightmare for hospital staff.
A fistula is an all-hands-on-deck emergency involving not just the EP department but surgeons and many hospital staffers. A surgeon may have to perform emergency surgery to insert stents in the esophagus in order to close off the fistula, or the surgeon may have to cut out part of the damaged esophagus, which is particularly risky
(I remember one EP describing how he and his staff were running down a hospital corridor with their fistula patient close to dying, in order to get the patient to an operating surgeon.).
Esophageal Cooling Means Better Ablations: And as a bonus, using the esophageal cooling system enables EPs to do a more thorough better job. They can ablate all areas of the heart rather than avoiding areas too close to the esophagus or using lower power with shorter duration or less contact force.
When Will Esophageal Cooling be Available? For catheter ablation application, probably not soon. In the U.S and probably worldwide, Attune Medical’s ensoETM esophageal cooling system is already in use and approved for specific purposes, for example, in cases of brain damage where a patient needs to have their whole body cooled down. But not for catheter ablation
In the United Kingdom, it will first have to be approved by NHS. In the U.S., it may not need to go through the FDA approval process again. (But this is a very speculative observation.)

Will Ablation Centers Implement? It will probably require a great deal of marketing to make EPs and ablation centers aware of and actually start using the esophageal cooling system. And because Atrial-Esophageal Fistula is such a rare complication, centers may not be willing to invest in an esophageal cooling system.

References
If you are looking for Dr. Mark Gallagher’s talk in the AF Symposium brochure, it was not listed. It was presented on Friday, January 24, 2020 in the session “Advances in Pulmonary Vein Isolation (Session II.)”

See also Zagrodzky, J. et al. Fluoroscopy Reduction During Left Atrial Ablation After Implementation of an Esophageal Cooling Protocol. AFS2020-03 AF Symposium brochure abstract, p. 28. St. David’s South Austin Medical Center, 2020.

Late-Breaking Clinical Study Evaluates Attune Medical’s ensoETM for Use During Cardiac Ablation Procedures. EPDigest. February 3, 2020. https://www.eplabdigest.com/late-breaking-clinical-study-evaluates-attune-medicals-ensoetm-use-during-cardiac-ablation-procedures

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

Return to 2020 AF Symposium Reports

2020 AF Symposium: After Diagnosis, How Soon Should an A-Fib Patient Get an Ablation?

2020 AF Symposium

After Diagnosis, How Soon Should an A-Fib Patient Get an Ablation?

by Steve S. Ryan

When you were diagnosed with A-Fib, did your doctor say, “Let’s wait a year or two and try different drugs before we send you for a catheter ablation.” Is this attitude justified by current research?

Karl-Heinz Kuck, MD

Dr. Karl-Heinz Kuck of St. Georg Hospital in Hamburg, Germany discussed this most important topic for patients in his presentation “ATTEST Trial―Impact of Catheter Ablation on Progression from Paroxysmal to Persistent AF.”

Heavy Decision for Electrophysiologists (EPs): When to Ablate

Dr. Kuck started by describing how he personally is affected by the strategic decisions he has to make every day. As an EP, “when should we ablate a patient with A-Fib?” Should we just look at symptoms (not considering anything that is caused by A-Fib).

Will this decision contribute to a patient moving into persistent forms of A-Fib?

This happens all too often―within one year, 4% to 15% of paroxysmal A-Fib patients become persistent.

Persistent A-Fib Patients at Higher Risk

Patients who progress to persistent A-Fib are at a higher risk of dying, they have more risk of stroke, 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.

ATTEST stands for “Atrial Fibrillation progression randomized control trial“

ATTEST: 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: RF Ablation vs Antiarrhythmic Drugs

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 Conclusion

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

His advice: “Ablate as early as possible.”

Editor’s Comments

Don’t Leave Someone in A-Fib―Ablate as Early as Possible: Dr. Kuck’s ingenious 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 Guidelines list catheter ablation as a first-line choice. That is, A-Fib patients have the option of going directly to a catheter ablation.
Know Your Rights—Be Assertive: I occasionally hear of Cardiologists who refuse to refer patients for a catheter ablation, who tell patients a catheter ablation is unproven and dangerous.
When you hear something like that, it’s time to get a second opinion and/or change doctors.
As an A-Fib patient, you should know your rights and be assertive—that according to the guidelines, you have a right to choose catheter ablation as your first choice.
Your doctor may try to talk you into first trying antiarrhythmic meds before offering you the option of a catheter ablation. That is so wrong!
 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 sinus.
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.
Thanks for Sharing, Dr. Kuck! I am particularly grateful to Dr. Kuck for sharing his own anxieties and decision-making strategies when trying to determine when a patient should get a catheter ablation, how this affects him personally.
Making decisions about patients whom one cares about isn’t always easy. But Dr. Kuck’s research should now make these decisions easier both for EPs and for patients.

The Bottom Line for Patients: It’s safer to have an ablation than to not have one. For more see my article Live Longer―Have a Catheter Ablation!

References
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, 3634.

Dobkowski, Darlene. ATTEST: Radiofrequency ablation superior to antiarrhythmic drugs for AF progression. October 10, 2019. Healio, Cardiology Today. https://www.healio.com/cardiology/arrhythmia-disorders/news/online/%7B5fa2c711-a459-4c62-bb46-8fad6c69c9ea%7D/attest-radiofrequency-ablation-superior-to-antiarrhythmic-drugs-for-af-progression

Kuck, K-H. Late-Breaking Science in Atrial Fibrillation 1. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019;

Paris Peykar, S. Atrial Fibrillation. Cardiac Arrhythmia Institute/Sarasota Memorial Hospital website. Last accessed Jan 5, 2013. URL:http://caifl.com/arrhythmia-information/atrial-fibrillation/↵

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

Return to 2020 AF Symposium Reports

2020 AF Symposium: “Virtual Heart” Assists Actual Ablations

AF Symposium 2020

“Virtual Heart” Assists Actual Ablations

by Steve S. Ryan

We have previously described the innovate, exciting work of Prof. Natalia Trayanova of Johns Hopkins Un. in Baltimore, MD. See ‘3D Virtual Heart’ Predicts Location of Rotors (2017 AF Symposium) and The Virtual Heart Computerized Simulation (2015 AF Symposium).

N. Trayanova, MD

At the 2020 AF Symposium, Prof. Natalia Trayanova of Johns Hopkins University presented “Computationally Guided Personalized Targeted Ablation for Persistent AF.” This computerized model is used to simulate an individual patient’s heart. This ‘Virtual Heart’ can then be used to guide an individual patient’s therapy.

Significant for Persistent A-Fib: For patients with Persistent Atrial Fibrillation, this computerized model is especially important. In a simple case of A-Fib, ablating/isolating the Pulmonary Veins (PVs) is usually all that’s necessary to restore a patient to sinus.

But with persistent A-Fib, it’s frequently required to do more than isolate the PVs. Persistent A-Fib patients often have fibrosis (fibrotic substrate) which perpetuates re-circulating electrical waves (rotors). The Virtual Heart identifies these fibrotic areas which sustain A-Fib.

How the Virtual Heart Works

Dr. Trayanova and her team start by doing an MRI scan. Then they hyper-enhance segments which correspond to areas of fibrotic remodeling in a patient’s heart.

The next step is to develop a computational mesh that incorporates representations of ion channels, calcium cycling and other electrophysical aspects of an individual’s atria. All this is incorporated into patient-specific geometry of the model.

Virtual-Heart-OPTIMA-approach-flowchart.

What the Model Can Reveal: They run the model to see what the arrhythmia looks like.

• Does the fibrotic substrate anchor rotors in particular locations?
• What are the spatial characteristics of the regions where they are located?
• Can these spatial metrics guide where the proper ablation should be?
• Can we reliably predetermine ablation targets?

Dr. Trayanova’s team merges these virtual atria with an advanced imaging technology (CARTO 3 System) to predict where the catheter should ablate.

The “Virtual Heart” Identifies Rotors: Prof. Trayanova found that re-entrant drivers (rotors) persisted in areas of higher fibrosis density and entropy (lack of order or predictability). They didn’t persist in regions of non-fibrotic sites and regions of deep fibrosis. The Virtual Heart is designed to completely eliminate the ability of the fibrotic substrate to sustain A-Fib.

Dr. Trayanova compared the predictive ability of her models to actual ECGI mapping cases from the Bordeaux group. Overall, her prediction of where rotors would be found coincided with where rotors were actually found by ECGI.

First-In-Human Virtual Ablation

Dr. Trayanova made major news when she announced the first-in-human clinical study of her Virtual Heart system! The first ten patients were part of an FDA approved clinical study of 160 persistent A-Fib patients called OPTIMA―Optimal Target Identification via Models of Arrhythmogenesis.

These ten patients had MRI heart scans which showed the fibrosis/scarring in their hearts.

This is a personalized approach tailored for each patient. The amount and structure of fibrosis is different in each individual.

Schematic summarizing the process of importing OPTIMA ablation targets into CARTO.

Creating Digital 3-D Models: Dr. Trayanova and colleagues then created digital 3-D models (Carto) and duplicated digitally the substrate and areas of fibrosis in individual patients.

They filled this model with digital virtual heart cells which mimicked and became a computerized duplicate heart. This digital heart behaved just like that individual patient’s real heart.

This digital heart behaved just like that individual patient’s real heart.

Then, they stimulate/pace the virtual heart electrically in many different locations to see where a stimulus produces an irregular heartbeat or rotor.

Rounds of Virtual Ablation: At this point, they performed several rounds of virtual ablation to digitally ablate those areas. Again, they tested to see if the digital ablation scars generated sites of emergent activity.

By the third round, there are no more hidden areas that can cause abnormal electrical signals. “We repeat the process till the substrate is no longer inducible for AF.” This also targets latent atrial arrhythmias, such as those that might emerge following initial ablation.

The Patient’s Digital Model: Finally, they export the digital model of the patient’s heart with all the A-Fib sites/rotors marked for the EP doing the actual ablation. In the EP lab, the EP uses this map to guide the catheter to the areas that need to be ablated.

Success of First Ten Patients

Persistent A-Fib patients, in general, are the most difficult to return to normal sinus rhythm. Around 50% of these patients have recurrences and have to return for additional ablations (which often cause yet more scar tissue).

Of Dr. Trayanova’s first 10 persistent patients in the OPTIMA procedure, only one patient had to return for a Flutter ablation (this was mostly because they ran out of time during the first ablation). In particular, all the rotor sites were correctly identified and ablated.

Editor’s Comments:

Persistent A-Fib patients are perhaps the most difficult to make A-Fib free.
Today, it’s common for even the best Master EPs to bring back persistent A-Fib patients for a second and even a third ablation before restoring them to sinus.
This may change with deployment of the Virtual Heart system.
The Virtual Heart system extensively and repeatedly maps where all A-Fib signals are coming from in a particular patient’s heart. With this mapping, the EP knows exactly where to ablate, including “hidden” areas which could emerge after a preliminary ablation, and areas that would cause electrical misfiring in the future.
Very important, with the Virtual Heart ablation there is no or very little recurrence of A-Fib.
The Virtual Heart system represents a major breakthrough in the treatment of persistent A-Fib patients.
The potential of Dr. Trayanova’ s research for A-Fib patients is incredible!
Imagine getting an MRI and knowing where your A-Fib is coming from, how your A-Fib affects and works in your heart both now and in the predictive future, how various A-Fib drugs can be expected and predicted to affect your heart, how much and what kind of fibrosis you have, how you can expect your fibrosis to progress and affect you over time, what therapies should be done in your particular case.
Imagine…if you need a catheter ablation, your EP knows exactly where to ablate in your heart.
Imagine…being able to accurately predict whether or not or how fast you will progress from paroxysmal to persistent A-Fib.
Imagine…all based on computer models that mirror your own heart.

Dr. Trayanova’s research has the potential to radically change the way A-Fib is treated. Almost all the uncertainties EPs and A-Fib patients now have to deal with can potentially be eliminated with the virtual computer reconstruction of individual A-Fib hearts.

References
Trayanova, N. A. Custom Cardiology: A Virtual Heart for Every Patient; Personalized computer models will let cardiologists test life-saving interventions. IEEE online, 28 Oct 2014. Accessed Feb 26, 2015, URL: http://www.ieee.org/about/index.html

Scudellari, Megan. Personalized Virtual Hearts Could Improve Cardiac Surgery―Digital replicas of patients’ hearts can identify hidden, irregular heart tissue for surgeons to destroy. IEEE Spectrum, August 22, 2019 / 12:00 GMT https://spectrum.ieee.org/the-human-os/biomedical/imaging/virtual-hearts-improve-cardiac-surgery

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

Return to 2020 AF Symposium Reports

2020 AF Symposium Live Case: Ultra-Low Temperature Cryoablation

AF Symposium 2020

Live Case: Ultra-Low Temperature Cryoablation

Background: The Adagio Medical iCLAS catheter is a Cryo catheter that uses ultra-low temperatures and is unlike anything currently on the market. To learn more about the iCLAS catheter, see my earlier report from the 2018 AF Symposium: Innovative iCLAS Cyro Catheter by Adagio Medical.
Note: The Adagio Medical iCLAS is not yet FDA approved. The U.S. IDE study trial is active and enrolling. The clinical trial started in December 2019. https://clinicaltrials.gov/ct2/show/NCT04061603.

Live Ablation Via Streaming Video

Tom DePottee, MD

Live from Belgium, Dr. Tom De Potter and his colleagues from OLV Hospital performed an ablation using Adagio Medical’s ultra-low temperature cryoablation catheter.

When the Symposium audience joined the live ablation via streaming video, Dr. De Potter and his colleagues had already performed a single transseptal puncture and were working in the left atrium.

Several catheter configurations possible with the Adagio Medical system.

To produce temperatures as low as (minus) –196° Celsius, Adagio Medical uses what they call Near Critical Nitrogen (NCN) which is far lower than current CryoBalloon technologies.

Producing Continuous Linear Ablations

Adagio catheters produce continuous linear ablations and can also be configured to do focal (single point) catheter lesions. Dr. De Potter also showed how the same Adagio Medical catheter can also do cryo mapping.

As we watched, Dr. De Potter encircled the Left Superior Pulmonary Vein (PV) with a double loop catheter. Then applied the cryo energy and froze the ostium area to isolate the PV. The catheter stylus included a loop of the freezing section and a loop with electrodes which recorded/mapped the A-Fib signals.

Freezing Isolated the Vein

We could see the ice formation on the catheter itself and how the freezing isolated the vein.

Adagio catheter encircles PV and freezes to isolate the PV area.

It only took 30 seconds to isolate that vein, but Dr. De Potter continued the freeze for one minute. Then performed what he called a bonus freeze.

On the catheter monitor, we could see how that vein had PV potentials which were then isolated.

Then Dr. De Potter moved to the Right Pulmonary Veins. The phrenic nerve usually runs close to the ostia of the right PVs. He said they perform phrenic nerve pacing to prevent damage to the phrenic nerve. We saw how they performed phrenic nerve capture.

Monitoring the Phrenic Nerve

If they do find they might be damaging the phrenic nerve, they don’t ablate there or insert a different catheter stylus configuration which doesn’t affect that area.

They didn’t achieve isolation of the Right Interior PV, so they did a second ablation while slightly changing the stylus loop position. Dr. De Potter said that he usually achieves isolation with one pass, except for, as in this case, with the Right Interior PV which is more challenging.

Protecting the esophagus with the Adagio Medical Warming Balloon (right of heart)

CryoAblation is Reversible. Dr. De Potter showed how they first used low energy cryo in a 30 second ablation to see if the phrenic nerve was affected (if affected, the tissue can be de-frosted and returned to normal or reversed.) Then they applied the full cryo energy at the ultra-low temperature which is permanent. The speed of decrease in cooling is very fast at 300°C/sec.

Protecting the Esophagus

To protect the esophagus, Dr. De Potter showed how they insert a warming balloon with constantly circulating warm saline into the esophagus which prevents excessive cooling and damage to the esophagus.

He stated that the next generation of the warming balloon will also have temperature sensing. They can then have a much better idea of what the freezing will do to the esophagus, how much temperature affects will be seen in the esophagus.

Ablating the Posterior Wall 

Dr. De Potter also showed the Adagio Medical system ablating the posterior wall. “It’s very simple. We will make overlapping rings.”

We saw him make those overlapping ring ablations in three passes which blocked conduction over the posterior wall. But with a larger atria, he may use 6 applications. He mentioned that at this stage he hasn’t achieved consistent success making a Mitral Isthmus line.

The Key Benefit of Ultra-Low Temperature Cryoablation

According to Dr. De Potter:

“The key benefit of this technology is a different energy source in contrast to the CryoBalloon which uses a theoretical minimum of –80°C.

This system (Adagio Medical) uses liquid nitrogen which has a theoretical minimum of –196°C. When you consider that this –80°C is at the center of the balloon and not necessarily at the tissue, we think we have a far better margin for efficient energy delivery while providing for patient safety.”

Editor’s Comments:

When I visited the Adagio booth at the Symposium exhibit hall, I was fascinated to see how easily the catheter can be manipulated into many different configurations depending on the lesions which need to be made.
Using its full length, the catheter can produce ultra-low temperatures along its whole span (110mm). Its 20 electrodes can also produce cryo-mapping of the atria.
Why is the iCLAS Cryo catheter special and innovative? The iCLAS catheter produces ablation lesions like current CryoBalloon catheters but at lower temperatures (colder). One would expect that such ultra-low Cryo lesions would be deeper, more transmural, and more lasting.
In addition, the ability to produce unlimited shapes gives the iCLAS catheter a unique ability to position Cryo lesions in a variety of locations in the heart.

The Adagio Medical iCLAS cyro system will make ablations much simpler and easier for EPs. It may eventually supersede normal CryoBalloon ablation (which is already a very effective ablation strategy).

If you find any errors on this page, email us. Y Last updated: Saturday, May 23, 2020

Return to 2020 AF Symposium Reports

Follow Us
facebook - A-Fib.comtwitter - A-Fib.comlinkedin  - A-Fib.compinterest  - A-Fib.comYouTube: A-Fib Can be Cured!  - A-Fib.com

A-Fib.com Mission Statement

We Need You

Encourage others
with A-Fib
click to order.


A-Fib.com is a
501(c)(3) Nonprofit



Your support is needed. Every donation helps, even just $1.00.



A-Fib.com top rated by Healthline.com since 2014 

Home | The A-Fib Coach | Help Support A-Fib.com | A-Fib News Archive | Tell Us What You think | Press Room | GuideStar Seal | HON certification | Disclosures | Terms of Use | Privacy Policy