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Catheter Ablation

A-Fib Free Again: My 3rd Ablation for “Very Late Recurrence” by Dr Natale

The return of my A-Fib was captured by my Medtronic Reveal LINQ loop recorder. I was asymptomatic, often referred to as Silent A-Fib. (For more about my recurrence, see my earlier post: My A-Fib’s Back: Need a Touch-Up This Week)

A Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM) is one of the world’s smallest cardiac monitors—inserted just under the skin near the heart.

Medtronic Reveal LINQ insertable heart monitor

Medtronic Reveal LINQ IHM

Each night my Reveal Linq wireless monitor transmits that day’s data by wireless connection to my EP, Dr. Shephal Doshi.

I’m 80 years young and a very active runner, high jumper and weightlifter. While many EPs would likely prescribe A-Fib drugs, I chose a third “touch-up” ablation instead.

Very Late Recurrence: This ablation was for the condition called “Very Late Recurrence” where someone who has been A-Fib free for years develops A-Fib again. (Previously these cases were considered very difficult or even impossible to fix.)

Why does A-Fib sometimes recur many years later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.

Pre-ablation, Steve Ryan with Dr. Natale and his surgical nurse.

But thanks to the excellent research of Dr. Andrea Natale and his colleagues, “Very Late Recurrence” can now be fixed.

To learn more about Very Late Recurrence, see our article: After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?

My Third Ablation: My re-do catheter ablation was on August 19, 2021 and was performed by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.

Research has shown that “very late recurrence” of A-Fib is primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Isolation of these triggers results in a high success rate.

Beautiful quilt, Los Robles Hospital Cardiac admittance; Handmade by two staff nurses.

During my ablation, this is exactly what Dr. Natale found. Therefore, he isolated both my left atrial appendage and my coronary sinus to eliminate the locations of these triggers. (My pulmonary veins had remained isolated.) He also made a roof line and an “infero-posterior” line with RF to isolate the posterior wall of the left atrium. He  found non-PV electrograms/potentials in the left atrial septum, the floor of the left atrium, the left atrial lateral wall, and the anterior roof of the left atrium which he eliminated with RF ablation.

I was in the hospital overnight. Everything went fine. The only complication I had was irritation of the throat from being intubated. I had to return to the Los Robles emergency room, but they took care of that with medication.

A-Fib Free (Again): I’m temporarily on Multaq and of course the anticoagulant Eliquis.

I am in the three-month blanking period. This is the period when my heart is learning to beat normally again.

For now, I’m A-Fib free.


After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?

Even though catheter ablation is remarkably successful in restoring most paroxysmal A-Fib patients to normal sinus rhythm, a small number of these patients do have relapses (recurrences) sometimes many years out.

The main objective of this study was to understand why Atrial Fibrillation relapses years after successful electrical isolation of the pulmonary veins (PVs) in paroxysmal patients and whether the presence of comorbidities influence recurrence.

These are the questions Dr Andrea Natale and his colleagues at the Texas Cardiac Arrhythmia Institute were looking to answer.

Study Parameters

In this observational study, researchers at Texas Cardiac Arrhythmia Institute looked at 1,633 of their paroxysmal patients who had been A-Fib free for two years after their first or second catheter ablations, then suffered recurrences years later  (i.e., Very late recurrent).

What does 'Very Late Recurrent' mean?
It’s one of three way to describe the timeframe of A-Fib recurrence after ablation:
• Early recurrence = During the 1-3-month “blanking period”;
• Late recurrence = 3–12 months after ablation;
• Very late recurrent = 12+ months after ablation.

The patients were divided into two groups based on the presence or absence of comorbidities (presence of two or more diseases). The groups were:

Group 1: 692 patients with no comorbidities
Group 2: 941 patients with comorbidities

Comorbidity (co·mor·bid·i·ty) means presence of two or more diseases or medical conditions in a patient.

A-Fib and Common Comorbidities

The Group 2 patients had one or more of the following illnesses/conditions (comorbidities):

• Moderate to severe sleep apnea
• Diabetes mellitus
• Body mass index 30 kg/m² or higher (obese)
• Hypertension treated with multiple anti-hypertensive agents
• Low left ventricular ejection fraction (lower than 45%; normal is 50% to 75%)

Quality of Previous Ablations

The patients who experienced recurrences had been previously well ablated (one or two procedures.) Standard ablation procedures included PVI plus isolation of the left atrial posterior wall and the Superior Vena Cava (SVC):

• Their pulmonary veins were completely isolated of all PV potentials as confirmed by entrance and/or exit block. The electrical isolation was extended to the posterior wall contained between the PVs.
• Posterior wall isolation was performed using multiple ablation points covering the whole posterior wall.
• The SVC was mapped and isolated circumferentially in all patients. The atrial myocardial sleeves extend into the SVC for up to 2 to 5 cm. thus harboring ectopic pacing cells that provide the substrate for atrial arrhythmia. The Superior Vena Cava (SVC) is a known source on non-PV triggers.

Superior Vena Cava (SVC) is a known source of non-PV triggers.

Patient Follow‐up

Follow‐up was performed at 1, 3, 6, and 12 months with office visits, cardiology evaluation, 12‐lead electrocardiogram (ECG) and 7‐day Holter monitoring at 1, 6, and 12 months. After 1 year, patients were followed up annually with a 7‐day Holter and were asked to check their pulse regularly to monitor rate.

Ablation success was defined as absence of arrhythmia off antiarrhythmic drugs.

Ten-Year Recurrence Findings

At 10 years of follow-up, median time to recurrence was 7.4 years. The recurrence rate among the study patients was:

• Group 1 patients: 31.1% experienced recurrence (215 of 692)
• Group 2 patients: 51% experienced recurrence (480 of 941)

Redo Ablations

Patients with recurrence of their A-Fib, underwent a ‘re-do’ ablation:

• 201 in Group 1 patients
• 456 in Group 2 patients

Ablations targets at re-do:

• 561 patients received isolation of the Left Atrial Appendage (LAA) and Coronary Sinus (CS); 96 patients received left atrial lines and flutter ablation; 9 patients received re‐isolation of PVs;
• PV reconnection was not noted in any of the patients with two prior procedures. The SVC was found to be permanently isolated in 642 (97.7%) and no reconnection of posterior wall in 611 (93%) cases.

Top: Representative images showing a patient’s lesion sets during initial ablation. Bottom: 5 years later during the same patient’s re-do ablation.

Two-Year Results After Redo Ablation

At 2 years, 91.1% (134) of Group 1 and 94.4% (391) of Group 2 remained arrhythmia free! These patients received left atrial appendage (LAA) and Coronary Sinus (CS) isolation.

Of those who received left atrial lines and flutter ablation, results were poor with around 7% arrhythmia free.

Study Conclusions

The main objective of this study was to understand why Atrial Fibrillation relapses years after successful PV catheter ablation in paroxysmal patients and whether the presence or absence of comorbidities influence very late recurrences.

Despite permanent pulmonary vein isolation (PVI), very late recurrence was primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Ablation of these triggers resulted in high success rate (regardless of the comorbidity profile.)

The median time to recurrence was significantly shorter in patients with cardiovascular comorbidities.

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

These study results are remarkable! The study findings reinforce the crucial role of non-PV triggers in the relapse of A-Fib. Knowing how comorbidities shorten the timeline to A-Fib recurrence can motivate patients to improve their overall health.
If You’re Having an Ablation or Re-do Ablation: Besides isolating the Pulmonary Veins, talk with your doctor about mapping and isolating non-PV triggers i.e., from the Left Atrial Appendage (LAA) and Coronary Sinus (CS).
How can You Avoid Recurrence? Get rid of comorbidities. Even after the establishment of sinus rhythm, comorbidities contribute to the progression of A-Fib and its recurrence.
Very late recurrence was primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus.
While patients in Group 2 (with comorbidities) were able to be cured and restored to sinus rhythm just as well as patients without comorbidities, recurrence occurred sooner (5.6 years versus 7.4 years).
To postpone or avoid recurrence of your A-Fib, do what you can to get healthier. Lose weight if needed, get treatment if you have sleep apnea, address hypertension issues, manage your diabetes, stop smoking, moderate your  consumption of alcohol.
Why Does A-Fib Sometimes Recur Many Years Later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.
Last Thoughts: Have researchers like Dr. Andrea Natale discovered how to cure even the most difficult A-Fib cases? Isolating the LAA and the CS seems to be the key.

Are we close to a time where even the most difficult cases of A-Fib can be cured by the right EPs using the right ablation techniques at the right time?

Resource for this article
Mohanty, S. et al. Natural History of Arrhythmia After Successful Isolation of Pulmonary Veins, Left Atrial Posterior Wall, and Superior Vena Cava in Patients With Paroxysmal Atrial Fibrillation: A Multi-Center Experience. Journal of the American Heart Association, 2021;10:e020563.

My A-Fib’s Back: Need a Touch-Up This Week

On August 19 I’m scheduled for a touch-up ablation by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.

Dr. Shephal Doshi and Steve Aug 1 2019

I’m symptom free. But my Medtronic Reveal LINQ loop recorder shows I still have some A-Fib after a catheter ablation by Dr. Shephal Doshi at St. John’s hospital in Santa Monica 24 months ago (August 2019).

Background: My first catheter ablation was in 1998 by Drs. Michel Haïssaguerre, Pierre Jais, and Dipen Shaw in Bordeaux, France. Though it was relatively primitive compared to what EPs are doing today, it kept me A-Fib free for 21+ years.

Steve with Dr Häissaguerre who cured Steve in 1998.

Left Atrial Appendage: During the touch-up ablation, my Left Atrial Appendage (LAA) may have to be electrically isolated. If that’s done, and my LAA doesn’t empty of blood properly, I may have to have a Watchman device inserted to mechanically close off my LAA. As an enthusiastic runner/sprinter, I don’t want to have my LAA closed off as it can reduce blood flow. But at 80 years old, I may have little choice. I’ll post again after my redo ablation.

A “re-do” catheter ablation is nothing to be frightened of. My procedure this week, like last time, will be as an out-patient. For my 2019 touch-up procedure, I arrived at the hospital at 5am and was back home at 5pm. In and Out. Lickety-split!

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.  MARCH 03, 2021. May-June 2021 Issue.


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

• Virtual ACC: Ethanol infusion in vein of Marshall improves catheter ablation outcomes. Cardiac Rhythm News, March 29, 2020.

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

Return to 2021 AF Symposium Reports

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.

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

Return to 2021 AF Symposium Reports

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