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

My A-Fib RF Catheter Ablations: 1998 vs 2019

When I developed paroxysmal Atrial Fibrillation in 1997, I was very symptomatic. This time, in 2019, I didn’t have any symptoms—instead my A-Fib was detected by my tiny, inserted Medtronic Reveal LINQ loop monitor/recorder.

More Differences Between 1998 and 2019

Since 1998, the treatment of A-Fib by catheter ablation has advanced by light years including 3D Mapping and ablation systems and catheter technologies.

My last ablation 21 years ago in Bordeaux, France lasted eight+ hours. This one at St. John’s Hospital in Santa Monica, CA took only 2-3 hours.

In Bordeaux, I was in the hospital for 9 days (mostly for observation, and a “touch up” second EP lab visit). In 2019, I was in and out in 12 hours.

Second Time Around: My A-Fib Catheter Ablation Prep

Steve Ryan pre-op A-Fib ablation

Pre-op: Steve with nurse inserting IV

On Thursday, August 1st, my wife, Patti, and I arrived at St. John’s around 5:30 am.

The nurses did the usual insertion of an IV port. They had trouble getting into my left arm and used the right. Then they shaved not just my groin but my chest and back too so that they could more easily attach the electrode pads for the mapping system (those pads were cold).

Then they wheeled me into the EP lab where it seemed like an army of people were waiting on me (probably around 8 people.) They were very friendly and super-efficient in their gowns and face masks.

Dr. Shephal Doshi of Pacific Heart Institute did my RF catheter ablation. (Both he and the anesthesiologist visited me in pre-op before the ablation.) Dr. Doshi has an excellent rapport with the staff and has a great sense of humor.

Out Like a Light

Before I knew it, they had a mask over my face, and I was out like a light. (Dr. Doshi said I was a “cheap date.”)

Mapping of my A-Fib heart - Steve Ryan August 2019

Mapping screen showing my A-Fib heart – the dots are the ablation lesions – notice the tight arrangement; Steve Ryan August 2019

Thanks to Dr. Doshi, we have loads of photos of my RF catheter ablation taken from the EP lab control room and some from inside the EP lab. (I intend to get an explanation of each screen from him to share with you later.)

Post-Ablation Recovery

I didn’t wake up until in the recovery room. Dr. Doshi said everything went very well. I will give you more technical details as I learn them (I don’t remember much of what he said at the time.)

He told Patti that indeed he could see the ablation lesions from my first ablation in 1998, which were around just two of my pulmonary veins (and some other areas). So, no wonder I needed a “touch-up”.

I don’t know too many details from 1998—I didn’t know to ask for the Operating Room (OR) report back then.

Post op: Dr Doshi and nurse Jamie removing Steve’s groin stitch.

To close the one catheter incision point in my right femoral vein, he used some kind of sliding figure-eight stitch that could be loosened or tightened as needed. That stitch was painful and hurt for a while. It was removed before I left the hospital.

In the recovery room I remember them bringing me a vegetable soup which tasted delicious. Patti fed me bits of a lunch of chicken salad and raw vegetables, low-fat milk and pineapple chunks.

I was discharged about 4:30pm. After a stop at the pharmacy, we were home by 6pm. Amazing compared to my first catheter ablation in 1998. In and out in under 12 hours!

Meds: Pantoprazole and Xarelto

Dr. Doshi said I have a large esophagus so he was concerned about acid reflux damage. To prevent the very rare complication Atrial Esophageal Fistula, I was given a prescription for the Proton Pump Inhibitor Pantoprazole SOD 40 mg to be taken once a day. I did have some acid reflux the first day, but none since I started taking the Pantoprazole. (For more about Atrial Esophageal Fistula , see Dr. David Keane’s AF Symposium 2014 presentation, “Complications Associated with Catheter Ablation for AF”.)

And I’m continuing to take Xarelto 20 mg (rivaroxaban) at night with a meal (I was also on it two weeks prior to my ablation).

Recovering at Home

Dr. Shephal Doshi and Steve Ryan before his A-Fib catheter ablation Aug 1 2019

My wife, Patti, drove me home that evening. I felt terrific. But that wasn’t to last.

No problems with my heart, but the next night (Friday), I developed a low-grade fever and felt very weak and unbalanced the next day. I slept a lot Saturday and felt better.

Sunday I was scheduled to be a lector at our local Catholic church. ­(I tried to get someone to sub for me but couldn’t find anyone.) I did read the scriptures for our congregation and felt fine. But went straight home after (I wouldn’t recommend this for everyone). One needs rest after an ablation.

As I write this Sunday night, I feel fine, just a bit tired. I’ll write more when I talk with Dr Doshi about my fever and after my two-week checkup.

My Catheter Ablation was a Success—I was Home the Same Day

My A-Fib catheter ablation “touch up” went off without a hitch. Dr. Shephal Doshi had me in the cath lab by 8am, out by 11am, discharged by 5pm. I feel great! (but no heavy lifting or workouts for two weeks.)

Thanks to all who emailed with good wishes, positive thoughts and prayers for a safe and successful ablation.

Look for my post with the details on Monday.

Steve Ryan in the cath lab St John Hospital before ablation on Aug 1, 2019

Steve Ryan, prepped in the cath lab at St John Hospital, Santa Monica, CA, before a catheter ablation for his asymptomatic, paroxysmal atrial fibrillation.

 

My 20-year Warranty Ran Out! My A-Fib is Back!

I had my catheter ablation twenty years ago and was blessedly A-Fib free till age 78. This past autumn my A-Fib reared its devilish head once again.

During a medical exam in August 2018, one of my doctors (not a cardiologist) detected an irregular heart beat. When my EP took my ECG, he didn’t detect A-Fib (thank goodness) and I didn’t have any symptoms.

Medtronic Reveal LINQ insertable heart monitor

Medtronic Reveal LINQ

But, just to be sure, he implanted a tiny wireless heart monitor so he could review my heart activity over time.

A few months ago, the Medtronic Reveal LINQ loop monitor/recorder showed I had one asymptomatic A-Fib episode up to 15 hours long and one 5-second pause during my sleep at 3:00 am.

Read my earlier posts about the return of my A-Fib:

• Sept 2018: Has My A-Fib Returned? I Get an Insertable Wireless Monitor
• Oct 2018: Part 2: My Medtronic Reveal LINQ loop recorder—21-Day results
• Nov 2018: Part 3: PVCs/PACs but No A-Fib; False positives from my LINQ Monitor

You can also read my full A-Fib story (the first A-Fib.com story).

My A-Fib Recurrence Not Surprising

My A-Fib recurrence didn’t come as much of a surprise. My catheter ablation back in 1998 was primitive compared to what EPs are doing today. I had what was called at that time a “focal point catheter ablation”.

Steve Ryan - A-Fib free since 1998 - active lifestyle

Steve Ryan, A-Fib free since 1998, doing the high jump.

Back in 1998, they actually ablated inside just one of my pulmonary veins (PVs) to eliminate the A-Fib signal source. (Today they don’t ablate inside a PV anymore because of the possible danger of causing stenosis/swelling of the PV. Instead, they ablate/isolate at the openings of the PVs to block A-Fib signals from entering the left atrium from the PVs where most A-Fib signals come from.)

Also back then along with my A-Fib, I also had a lot of pauses. But they disappeared after my catheter ablation in 1998. A successful catheter ablation often eliminates these pauses, which is one of the reasons I chose to have a catheter ablation.

Strenuous Lifestyle: 20 Years is Not Enough

Steve Ryan - sprint training

Steve Ryan sprint training

What’s surprising is not that my A-Fib re-occurred, but how long my relatively primitive ablation lasted. In effect, none of the openings to my PVs back in 1998 were electrically isolated from the rest of my heart (just inside one PV).

But nevertheless, I remained A-Fib free for 20 years while participating in very demanding, strenuous training and activities such as Masters Track meets.

I want another 20 years!

Choosing Ablation Rather Than A-Fib Drugs

I was offered the treatment option of just taking A-Fib drugs (I was asymptomatic). I chose instead to have a modern catheter ablation which will be performed Thursday, August 1st by Dr. Shephal Doshi at St. John’s hospital in Santa Monica, CA.

Also, I don’t want to be on today’s A-Fib drugs if I can avoid them.

Today’s Advanced Mapping Techniques

Dr. Doshi will identify and isolate the openings to my pulmonary veins so A-Fib signals from the PVs can’t get to the rest of your heart.

Dr Fishel RF catheter ablation video

Ablation 3-D modeling screen

But that’s not the only possible source of A-Fib signals. A-Fib can develop from other areas of the heart such as the right atrium, left atrial appendage (LAA), transeptal wall, coronary sinus, etc.

So, Dr. Doshi will use advanced mapping technologies not avaliable in 1998 to look for, then isolate, any other areas of the heart which produce A-Fib signals. His goal is to identify and isolate all A-Fib signals no matter the source.

In the final step of the ablation, he will use a drug or a electrical stimulation (passing) to try and stimulate my heart back into A-Fib—hopefully with no success.

Your Positive Thoughts and Prayers Please!

That Demon on Your Shoulder Called ‘A-Fib-Zebub’

Ridding myself of that demon ‘A-Fib Zebub’

Like so many of our A-Fib.com readers having an ablation, I ask you to please keep me in your thoughts/prayers, especially August 1st.

I have every confidence that this ablation will be a “touch-up” job, and I will once again be A-Fib free.

I expect only a one-night stay in the hospital. Patti and I will report in ASAP afterward to give you an update.

Can One Have a Stroke If A-Fib Free? Years After Successful Ablation, He has TIAs

Steve from Minnesota had a successful catheter ablation in 2016 at the Mayo Clinic. He remained in normal sinus rhythm (NSR), off all medications and felt very good. He walked every day and felt well.

TIA symptoms are the same as a stroke, and usually begin suddenly. The difference is the symptoms only last for a few minutes or hours as the blockage is temporary.

Recently he wrote to me that in the fall of 2018, he had a TIA (Transient Ischemic Attack, a temporary stroke) where his left arm went limp for about 30-60 seconds. Then in March 2019, another TIA caused him to lose complete vision in his left eye for 2-3 minutes.

In response, his electrophysiologist (EP) put him on the anticoagulant Eliquis. He wore a loop monitor which showed he was in normal sinus rhythm with only a single “5-beat atrial tachycardia” (only one irregular beat). All the usual tests came back showing no heart problems.

How can Steve have TIAs if he doesn’t have any A-Fib?

Unfortunately for A-Fib patients, clots and stroke can also be non-A-Fib related, such as vascular strokes or hypertensive lacunar stroke. (Vascular and cerebrovascular disease can produce a heart attack or coronary event as well as a clot or stroke.)

With A-Fib patients, clots more often come the Left Atrium and Left Atrial Appendage (LAA). But stroke can originate from other areas. For example, plaque deposits in the arteries can break loose and form clots.

Also, if Minnesota Steve developed some fibrosis while he was in A-Fib, his left atrium may not be contracting properly making clot formation more possible. And sometimes if the LAA is electrically isolated during the ablation, it may not be contracting properly and can develop clots.

(Doctors may want to check Minnesota Steve for Patent Foramen Ovale and Atrial Septal Defect where a hole in the septum can permit clots to pass to the brain. Though, normally, this problem would have been found when performing Steve’s original ablation.

A transient ischemic attack (TIA) occurs when part of the brain experiences a temporary lack of blood flow. This causes stroke-like symptoms that resolve within 24 hours. Unlike a stroke, a ministroke on its own doesn’t cause permanent disabilities.

Would a Watchman device to close off the LAA prevent these TIAs?

Not necessarily. For patients with A-Fib, clots tend to form in the Left Atrial Appendage (LAA) because blood tends to stagnate there. But if blood is being pumped properly in the left atrium, it’s harder for clots to form in the LAA. (And other areas of clot formation can occur in the left atrium besides the LAA.)

What should Steve do now? What can he do to guarantee that he will never have a stroke?

Having TIAs is a warning sign. Often, but not always, TIAs precede a major stroke. To help guard against clots and stroke, Minnesota Steve will likely have to be on an anticoagulant, such as Eliquis, for life.

What’s Next for Steve?

Minnesota Steve and his doctor should concentrate on treating vascular risk factors such as blood pressure, diabetes, cholesterol control, (CHADs2-VASc) and if needed, stop smoking. And, of course, continue monitoring for A-Fib.

Fibrosis makes the heart stiff, less flexible and weak, overworks the heart and reduces pumping efficiency.

Minnesota Steve probably should have an MRI done to measure for fibrosis in his heart. In addition, his Left Atrial Appendage (LAA) should be checked with a echocardiograph (TEE) to see if it is emptying properly.

His doctor may also want to determine how much plaque Minnesota Steve has in his arteries. How likely is it to break off and form clots? (Some doctors may suggest antiplatelet therapy in addition to the anticoagulant Eliquis, but usually the two are not combined effectively.)

I’ll continue to track Minnesota Steve’s progress and write an update if I get more information on his health status.

No Absolute Guarantee Against Stroke

While anticoagulants significantly lower the risk of an A-Fib stroke, they but do not totally eliminate it.

While anticoagulants significantly lower the risk of an A-Fib stroke, but they do not totally eliminate the risk.

A close friend of ours with A-Fib was on Coumadin at the ideal INR range (2.5) and still had a major stroke.

After a successful catheter ablation such as Minnesota Steve had, one’s stroke risk generally drops down to that of a normal person. But normal people have strokes and TIAs, too.

There is no therapy that will absolutely guarantee one will never have a stroke.

Share Your Views at A-Fib.comMinnesota Steve is blessed to have no permanent damage from those TIAs. But they are warning signs which must be heeded, probably by life-long anticoagulation. No one wants to be on anticoagulants for life. But he may not have any other choice.

Share your insights: Without a lot of current definitive research, this is a difficult subject to discuss. If anyone has any suggestions, criticisms, or comments to share on this most important topic, please email me.

A special thanks to Steve from Minnesota for asking this question and sharing his TIA experiences.

Your Nearest ‘Certified Stroke Center’ Could Save Your Life

or avert the debilitating effects of an A-Fib stroke.
But only if you get there within four hours.

Use my article to find your nearest certified or ‘Advanced Comprehensive Stroke Center’. Read my article.

Tony Rejects Drug Therapy: Says to Ask Questions, None are Stupid

Tony Hall, Evansville, IN, was 54 years old when he develped Atrial Fibrillation in January 2014. After confirming his diagnosis at the hospital, he wrote:

“I sit in the passenger seat feeling like a pet heading to a kennel. Suddenly things are different. I no longer have that “healthy as a horse” attitude.”

He started drug therapy. Then came a cardioconversion, but that didn’t keep him in normal sinus rhythm for long. He was in and out of A-Fib, and by August was in persistent A-Fib.

Learning His Treatment Options

Tony didn’t passively accept everything he was hearing from doctors and others.

He and his wife, Jill, read as much as they could and critically waded through the information they found. (I’m continually amazed at how much mis-information there is about A-Fib on the internet and in the media.)

5-months post-ablation, Tony and Jill after 10K race.

After doing his research, educating himself about treatment options and learning what his health insurance would cover, he chose to have a catheter ablation at the Mayo Clinic in December 2014.

During his three month blanking period, he had some sporadic fluttering and early on a couple of brief A-Fib episodes.

Off all medication and A-Fib-free, in March 2015 he completed a 10K race beating his time from the previous year by a fraction.

Becoming his Own Best Patient Advocate

Tony and Jill are great examples for all A-Fibbers of how to become your own best patient advocate. He rejected endless trials of various drug therapies. Instead he opted for a catheter ablation just shy of a year after his initial A-Fib diagnosis.

In his A-Fib story, he shares this advice to others considering a catheter ablation:

“Make sure, if you desire to have an ablation, that your reasoning is sound and that you have a good argument as to why drug therapy is not the way you want to go.
Having an ablation as front line treatment for A-Fib is not embraced by every EP, and many are reluctant to ablate until drug therapy has failed.
Be persistent and move on [to another doctor] if you are met with resistance.”

For Tony Hall’s personal experience story, see: Very Active 54-Year Old Became His Own Patient Advocate; Chose Ablation as First Line Treatment.

AF Symposium Two New Reports: Ablation Without Touching Heart and New RF Balloon Catheter

I’ve posted two of my reports from the 2019 AF Symposium.

Automated Robotic Ultrasound Ablation

From the Czech Republic via streaming video, a catheter ablation using an incredible new technology―Ultrasound Mapping and Ablation (Low-Intensity Collimated Ultrasound, LICU) from Vytronus, Inc. The catheter never touches the tissue!

From Vytronus VIDEO: Ultrasound Mapping and Ablation

The EP created a robotic lesion path for the ultrasound catheter to follow. Using electromagnetic navigation, the catheter automatically went to the spots and path the operator drew.

We watched as the catheter hovered over the heart surface while the highly directional ultrasound energy beam created the lesion lines—never touching the tissue. It was amazing to watch!

To learn more...go to my full report: Ablation Without touching the Heart Surface Using Ultrasound―Live Case from Prague.

Multi-Electrode Radio-Frequency (RF) Balloon Catheter

Multi-Electrode Radio-Frequency (RF) Balloon Catheter from Biosense Webster

The new irrigated Multi-Electrode RF Balloon Catheter from Biosense Webster is a “one-shot” delivery of RF energy and can burn lesions to isolate the Pulmonary Veins in minutes. And because the electrodes can be programmed to deliver less energy levels (for example near the esophagus), the RF Balloon Catheter can be safer and more effective than traditional RF point-by-point ablation.

It has 10 gold surface electrodes or heating bars which can be turned on and off or set to deliver different energy levels simultaneously. Each electrode is powered by its own generator.

While the AF Symposium audience watched the RF ablation live, the EP took just 7 seconds to isolate a particular vein―quite remarkable compared to the time involved for traditional RF.

To read my full report, go to: Multi-Electrode RF Balloon Catheter―Live Case from Boston Mass. General

2019 AF Symposium: Common Fluoroscopy Technology Converted to Real-Time 3D Images

Fluoroscopy is a type of medical imaging that shows a continuous 2D X-ray image on a monitor, (like an X-ray movie).

by Steve S. Ryan

Another medical breakthrough at this year’s AF Symposium featured an innovative mapping technology which turns normal fluoroscopy into real-time 3D imagery.

During a live CryoBalloon ablation from Milwaukee, WI, the system was used by Drs. Sabir Jra and Dr. Mohamed Hani of Aurora Health Care.

The Navik 3D Cardiac Mapping System from APN Health was FDA approved in 2016 and was first clinically used in March 2018. Dr. Jra is also the developer.

Real-Time Converting 2D to 3D: How the System Works

Commonly found in most every Electrophysiology lab is equipment for fluoroscopy. It’s a type of medical imaging that shows a continuous 2D X-ray image on a monitor (like an X-ray movie).

Monitor images Navik 3D system

The genius of Dr. Jra’s system is converting the familiar fluoroscopy into 3D real-time images.

The Navik 3D Cardiac Mapping System uses a complex mathematical formula and fast processor calculations to locate any opaque object (such as a catheter or a pulmonary vein opening) within regular X-ray fluoroscopy and turn it into a 3D image.

The Navik system uses real-time 2D, single-plane fluoroscopy images along with body surface ECG data and intracardiac echo signals to create a synchronized, real-time 3D visual map.

Real-Time 3D Images

As AF Symposium attendees watched the live CryoBalloon ablation, the mapping seemed to be very fast. It created and displayed real-time 3D maps of the cardiac chambers during the ablation, though the images appeared somewhat different from images from other 3D mapping systems.

Dr. Jra’s system can be integrated into a normal electrophysiology lab using typical procedure equipment. During the live procedure, his lab looked like other EP labs I’ve seen.

Editor’s Comments
3D Huge Improvement over Fluoroscopy: Dr. Jra’s work is innovative and a true medical breakthrough. It’s incredible—being able to convert, in real-time, fluoroscopic images into 3D images. Any electrophysiologist (EP) using fluoroscopy could, in theory, use Dr. Jra’s system.
Instead of X-ray images which are 2D and not all that clear, 3D images are a potentially huge improvement and would make the EP’s work more easily and clearly viewed.
Easy to Install and Use: The Navik 3D Cardiac Mapping System seems relatively easy and cost-effective to install. It doesn’t require major changes to an existing EP lab. But does require one addition piece of equipment, a body surface ECG system under the patient exam table.

Will 3D Fluoroscopy Become Widely Accepted and Used? Considering how many different excellent mapping and ablation systems are now being used, one wonders if Dr. Jra’s 3D fluoroscopy system will become accepted in today’s A-Fib marketplace, I’ll watch the rollout of the Navik 3D Cardiac Mapping System and report on its progress.

References for this article
Djelmami-Hani, M. Novel Approach to Cardiac 3-D Mapping. EP Lab Digest, Vol 18. Issue 9, Sept. 2018. URL: https://www.eplabdigest.com/novel-approach-cardiac-3d-mapping.

APN Health Receives FDA Clearance for Navik 3D Cardiac Mapping System. Diagnostic and Interventional Cardiology, February 29, 2016. URL: https://www.dicardiology.com/product/apn-health-receives-fda-clearance-navik-3d-cardiac-mapping-system

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

Return to 2019 AF Symposium Reports

AF Symposium: New Product Vascular Closure Device for Catheter Ablations

I just got off the phone with Andy who was telling me about his RF Ablation and his post-op experience. He had to lie on his back for 15 hours before his groin incision stopped bleeding and he was safe to go home. He said it was quite painful to be immobile that long.

Delivery disc of the  ASCADE MVP implants the collegan plug

My first report from the 2019 AF Symposium is about a new product used during catheter ablations and is designed to help patients like Andy go home sooner after their ablation.

The problem? Post-op bleeding from the catheter insertion point in the groin. Typically, the patient lies on their back for about 6 hours while the insertion point heals and stops bleeding enough so they can be discharged. (For guys, especially, it’s no fun having to use a Foley catheter to pee.)

Cardiva Medical has solved this problem. A simple, ingenious device closes off the insertion point(s) in the groin with a “collagen plug”.

Collagen plug like a cork in a bottle

How it’s used: After completing the ablation, the EP withdraws the ablation catheter, then replaces it with the VASCADE MVP which has a expandable/collapsible delivery disc to implant a collagen plug. This plug acts like a cork in a bottle and stops all bleeding leakage. (The FDA was so impressed with the VASCADE that it approved it within weeks.)

I give it a try: In the Exhibitors Hall, Michael Gebauer of Cardiva Medical demonstrated it to me. It takes a whole 5 seconds to insert the VASCADE MVP.

Continue reading (for how to get the cork out of the bottle, and more)go to my full report: Cardiva Medical ASCADE MVP Vascular Closure Device.

2019 AF Symposium: Multi-Electrode RF Balloon Catheter―Live Case from Mass. General

by Steve S. Ryan

Live streaming video-2019 AF Sympoium; A-Fib.comMassachusetts General Hospital in Boston, MA was the origination site for an ablation using a new irrigated Multi-Electrode Radiofrequency (RF) balloon catheter from Biosense Webster. Live via streaming video, were Drs. Moussa Mansour, Andrea Natale and Kevin Heist.

Multi-Electrode RF Balloon Catheter from Biosense Webster

While the AF Symposium audience watched the RF ablation live, the EP took just 7 seconds to isolate a particular vein―quite remarkable compared to the time involved for a traditional RF point-by-point ablation.

Multi-Electrode RF balloon catheter from Biosense Webster; A-Fib.com

Multi-Electrode RF balloon catheter from Biosense Webster

Catheter design: This new irrigated Multi-Electrode RF balloon catheter has 10 gold surface electrodes or heating bars which can be turned on and off or set to deliver different energy levels simultaneously. Each electrode is powered by its own generator.

In addition, rather than a fixed size, the 28 mm balloon is “compliant” and can fit into different-sized and shaped pulmonary vein openings.

Balloon catheters: This is the first RF balloon catheter in use for pulmonary vein (PV) ablation. Up to now balloon catheter technology has been used mainly with Cryoablation of the PV veins and the Laser Balloon catheter.

Approvals: In Europe, 200 patients have been treated with the Multi-Electrode RF balloon catheter. It is in trials in the U.S. and hasn’t yet been approved by the FDA.

Balloon Catheter also Creates 3-D Mapping

The 10 electrodes in the balloon also function as a circular mapping catheter to produce a 3-D map of the atrium and can pace the heart as well.

The liquid used to cool the RF burns flows at 35 nl/min. The RF is unipolar and heats at a maximum of 15 watts. RF lesions are made for 60 seconds, but the time can be reduced to 20 seconds when working on areas such as the posterior wall near the esophagus.

RADIANCE stands for “PV Isolation with a Novel Multi-electrode Radiofrequency Balloon Catheter that Allows Directionally-Tailored Energy Delivery”

RADIANCE multicenter study: The RADIANCE study was a multicenter study conducted between Dec. 2, 2016 and March 8, 2017 in Europe. A total of 39 patients with paroxysmal atrial fibrillation were treated with the Biosense Webster multi-electrode radio frequency (RF) balloon catheter at four centers with nine different operators from both the U.S. and Europe.

In the RADIANCE study, 100 percent of the treated pulmonary veins were electrically isolated without the need for “touch-up” lesions with a RF focal catheter (referred to as “one-shot” delivery).  The study showed the RF balloon catheter could deliver directionally-tailored energy using multiple electrodes for efficient acute PVI in patients with paroxysmal A-Fib. For more about the RADIANCE Study see Multi-Electrode RF Balloon Efficient for Acute Pulmonary Vein Isolation Study.

Editor’s Comments
Advantages of the new RF Balloon Catheter:
It is difficult with an RF point-by-point catheter to produce a solid circular lesion around the PVs in a beating heart. It can take hours.
By comparison, this new irrigated RF Balloon Catheter is a “one-shot” delivery of energy and can isolate (burn lesions) in the PVs in minutes. And because the electrodes can be programmed to deliver less energy levels (for example near the esophagus), the RF Balloon Catheter can be safer and more effective than traditional point-by-point ablation.
Compared to CryoBalloon Ablation: The question from a patient’s perspective is which is better or more effective? The newer RF Balloon catheter ablation (when FDA approved in the U.S.), or the current, already proven CryoBalloon ablation? Right now, there isn’t enough data to answer this question.
The RF Balloon ablation does have an advantage over traditional CryoBalloon ablation. It can deliver different energy levels to prevent deeper ablation damage. (Currently, potential damage to the esophagus is handled with displacement tools which move the esophagus away from ablation sites. For more on this, see Esophageal Displacement Tool.)

Bottom Line for Patients: Promising! I’m excited about the Multi-Electrode Radiofrequency (RF) balloon catheter from Biosense Webster. I’ll report on it again, hopefully when it receives FDA approval for use in the U.S.

Resource for this article
Fornell, D. Multi-Electrode RF Balloon Efficient for Acute Pulmonary Vein Isolation. Study presented at the Heart Rhythm Society’s 2017 Late-Breaking Clinical Trials Section. DAIC, May 17, 20Reference17. https://www.dicardiology.com/article/multi-electrode-rf-balloon-efficient-acute-pulmonary-vein-isolation

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

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AF Symposium 2019: Live from Prague—Ablation Without touching the Heart Surface Using Ultrasound

By Steve S. Ryan

On the second day of the AF Symposium attendees viewed, live from the Czech Republic, a catheter ablation using an incredible new technology―Ultrasound Mapping and Ablation (Low-Intensity Collimated Ultrasound, LICU) from Vytronus, Inc.

“Collimated” refers to focusing ultrasound rays so that they are parallel and spread out minimally with minimum divergence.

The procedure was via live streaming video from Na Homolce Hospital in Prague. The doctors performing the A-Fib ablation were cardiac electrophysiologists Jan Petru, Moritoshi Funasako, and Petr Neuzil.

Near-Real Time Ultrasonic Imaging of the Heart

The system first robotically scanned the left atrium and Pulmonary Veins (PVs) to create a 3-D global image of the heart anatomy in near-real time using the same dual-purpose transducer tip that makes the ablation lesions. (Later the same process was used to verify ablation lesions and the effectiveness of the ablation.)

Automated Robotic Ultrasound Ablation

In this automated robotic ablation, the LICU ultrasound catheter with a dual-purpose transducer tip didn’t touch the heart surface to make ablation lines.

The EP created a robotic path for the ultrasound catheter to follow. Using electromagnetic navigation, the catheter automatically went to the spots and path the operator drew.

We watched as the catheter hovered over the heart surface while the highly directional ultrasound energy beam created the lesion lines.

It was amazing to watch!

If the heart surface was thicker, the ultrasound catheter slowed down thereby increasing the ultrasound dose and energy delivered. This made the continuous lesions deep enough and transmural. The catheter didn’t touch or make contact with the heart surface.

Flowing Blood in the Heart Doesn’t Affect the Ultrasound Beam

The choice of ultrasound frequency (approximately 10 MHz) means that the ultrasound beam is affected very little by blood in the heart. Blood is “transparent” to the ultrasound beam.

This also means that the distance from the catheter tip to the targeted tissue isn’t critical and can vary. Also, the ultrasound catheter tip is irrigated to cool the tissue and prevent the formation of char or thrombus.

Color-Coded Range Map

The system uses a color-coded ultrasound-generated range map which displays how far the tip of the catheter is from the tissue to be ablated in order to create good lesions.

If the operator sees purple, blue or green, the catheter is within therapeutic ablation range. Yellow, orange and red indicate the catheter is beyond therapeutic range. The therapeutic range can vary from 5 mm to 50 mm.

During the live ablation, the EP said that dark blue is the best, while purple may be too close.

VIDEO: Product Animation. Ultrasound Mapping and Ablation (Low-Intensity Collimated Ultrasound, LICU) from Vytronus, Inc. (2:22 min.)

Video playback controls: Controls are located in the lower right portion of the frame: Click on arrow icon to select.

Editor’s Comments:
Background: In the past, high-intensity focused ultrasound (HIFU) caused esophageal injury and was withdrawn from clinical use. But Low-Intensity Collimated Ultrasound (LICU) operates at a lower acoustic intensity than the previous HIFU. Lesion formation occurs at a more gradual fashion.
Though not yet approved for use in the U.S., development of an ultrasound LICU ablation catheter and mapping system is a most important innovation for A-Fib patients.
Near-Real-Time Mapping: The ability of the ultrasound catheter to create 3-D images of the atrium and PVs at almost the same time as the ablation is a major advantage over other mapping systems. It creates more accurate rendering of the targeted heart features. In other systems there can be map drifts/shifts, inaccuracies from heart motion, respiratory motion, and volume-related chamber enlargement.
Non-Contact Ablation: In an ultrasound LICU ablation the catheter doesn’t touch the heart tissue. The EP doesn’t have to worry about “contact force” measurement, i.e., whether they are applying enough or too much force to make good transmural lesions.
Robotically Controlled Ablation Process: To me the robotic ultrasound LICU system seems easier to use. The ultrasound lesions were created automatically. As compared to standard point-by-point RF ablation or even CryoBalloon ablation, it’s remarkably simple and requires much less EP involvement and skill.
From a patient’s perspective, you aren’t as dependent on the skill and manual dexterity of the EP (or whether they are on top of their game that day).
A Breakthrough but Not Yet Available: It was obvious to everyone in the AF Symposium audience that we were witnessing the dawn of a potential new age in catheter ablation.
Though still investigational and not yet approved in the U.S., robotic low-intensity ultrasound mapping and ablation seems like a radical breakthrough in ablation treatment.

More Studies Needed: Many studies of its safety and efficacy need to be made before ultrasound ablation becomes available to patients. But low-intensity robotic ultrasound ablation looks really promising.

References for this article
Koruth, J.S. et al. Pre-Clinical Investigation of a Low-Intensity Collimated Ultrasound System for Pulmonary Vein Isolation in a Porcine Model. JACC: Clinical Electrophysiology, Vol. 1, No. 4, August 2015 http://electrophysiology.onlinejacc.org/content/1/4/306. DOI: 10.1016/j.jacep.2015.04.011

Vytronus, Inc. Ultrasound Mapping and Ablation (Low-Intensity Collimated Ultrasound, LICU),  the Vytronus LICU® system. URL: https://www.vytronus.com/technology/

If you find any errors on this page, email us. Y Last updated: Thursday, August 27, 2020

Return to 2019 AF Symposium Reports

 

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