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


Testing

Which Comes First: Sleep Apnea or Atrial Fibrillation?

Obstructive Sleep Apnea (OSA) affects about 100 million people worldwide with 85% of cases going undiagnosed.

Of Atrial Fibrillation patients, about 43% additionally suffer with Obstructive Sleep Apnea.

Could undiagnosed sleep apnea be linked to development of Atrial Fibrillation?

OSA Link to A-Fib

OSA is characterized by repetitive episodes of shallow or paused breathing during sleep that lead to a drop in blood oxygen level and disrupted sleep.

85% of Sleep Apnea cases go undiagnosed.

New research has found that patients with Sleep Apnea may be at greater risk of developing Atrial Fibrillation. Abnormal oxygen saturation level during sleep may be responsible.

Patients with OSA are more likely to have high blood pressure, or hypertension, which is a major risk factor for heart disease and other cardiovascular conditions.

Risk of New Onset A-Fib: The Clinical Cohort Study

Lead author Dr. Tetyana Kendzerska, Ph.D., of the University of Ottawa in Canada, and colleagues reviewed the records of 8,256 adults (average age 47) with suspected OSA. Individuals with any diagnosis of arrhythmias were excluded. Participants were followed for an average of 10 years. During that time, 173 developed A-Fib resulting in hospitalization.

Study Results

The reviewers found that the amount of sleep time spent with lower than normal oxygen saturation (below 90 percent) was a significant predictor of developing Atrial Fibrillation.

By contrast, the number of breathing pauses during each hour of sleep did not appear to affect A-Fib risk.

Study participants who developed A-Fib during the follow-up period were more likely to be older, current or former smokers, and have a high level of comorbidities (e.g. high blood pressure, or hypertension).

“The association between oxygen desaturation and A-Fib remains significant, suggesting that OSA can directly cause A-Fib.”

What This Means to Patients

In light of this study, a diagnosis of Atrial Fibrillation raises the question, ”Could my A-Fib have been brought on by undiagnosed Sleep Apnea?”

Sandy from Boston

Sandy from Boston and her doctor say ‘yes”. Updating her personal A-Fib story, she wrote:

“After my [successful] CryoBalloon ablation at BWH in 2014, I underwent a sleep study that revealed during REM sleep I stopped breathing an average of 32 times every hour. My physician suspected that my traumatic brain injury in 1995 caused my undiagnosed sleep apnea, which in turn caused Paroxysmal A-Fib. I have been using a CPAP ever since.”

Take Action: Sleep Apnea Can be Lethal: If you have untreated Sleep Apnea, you are at greater risk of having a more severe form of A-Fib or of not benefiting from an A-Fib treatment.

So many A-Fib patients also suffer from sleep apnea that many Electrophysiologists (EPs) routinely send their patients for a sleep apnea study.

Sleep apnea isn’t a minor health problem, and it’s a condition you can do something about. To learn more, see Sleep Apnea: When Snoring Can Be Lethal.

Resources for this article
Atrial Fibrillation and Sleep Apnea. Heart Rhythm Society. http://resources.hrsonline.org/pdf/patient/HRS_AF_SleepApnea_R3.pdf

What You Need to Know: Sleep apnea may increase atrial fibrillation risk. Brighsurf.com, May 22, 2017. https://www.brightsurf.com/news/article/052217429745/sleep-apnea-may-increase-atrial-fibrillation-risk.html

Kendzerska, T, et al. Sleep Apnea Increases the Risk of New Onset Atrial Fibrillation: A Clinical Cohort Study. American Thoracic Society. Public Release: 22-May-2017. https://www.eurekalert.org/pub_releases/2017-05/ats-sam051517.php

Whiteman, H. Obstructive sleep apnea might lead to irregular heartbeat. Medical News Today. May 23, 2017. https://www.medicalnewstoday.com/articles/317577.php

Does Size Matter? What’s the Size of Your Left Atrium?

When in A-Fib, your left atrium has to work harder than normal and tends to stretch and dilate over time. Thus, an enlarged heart, specifically your left atrium, can be one symptom of living with Atrial Fibrillation.

Other contributors to an enlarged left atrium are obstructive sleep apnea (OSA) and high blood pressure. Also, people with a naturally large or tall body size often have an enlarged left atrium (ELA).

Consequences of an Enlarged Left Atrium

One study showed that Persistent A-Fib was associated with left atrium size (but not the number of years that a patient had A-Fib).

Left atrium size is a predictor of mortality due to cardiovascular issues.

Left atrium size has been found to be a predictor of mortality due to both cardiovascular issues as well as all-cause mortality (although other factors may contribute).

As a result, some medical centers won’t do a Pulmonary Vein Ablation (Isolation) procedure if the left atrium is enlarged (over 5.5 cm). However, with the newer ablation techniques, other centers will. Surgeons also are reluctant to operate on someone with an enlarged heart.

Normal left atrium: 2.0-4.0 cm

Left Atrium Size: Normal vs Enlarged

An enlarged left atrim can be diagnosed and measured using an echocardiogram (ECHO). A normal left atrium measures around 2.0-4.0 cm (20 mm–40 mm).

Ranges: Left atrial enlargement can be mild, moderate or severe depending on the extent of the underlying condition.

Note: Measurement of the volume is preferred over a single linear dimension since enlargement can be different for different directions.

Why You Need to Know Your Measurement

If you’ve had A-Fib for a while with significant symptoms, we often advise you to ask your doctor for this measurement to see if your left atrium is being enlarged.

To rank the size of your atrium, see TABLELeft Atrial Size
It will be described in either centimeters (i.e. 2.0 cm) or millimeters (i.e. 20 mm).

Store this info with your other A-Fib test results and other papers in your A-Fib Binder or folder. This will be your benchmark for future comparison.

To rank the size of your atrium, go to TABLE: Indexing the Left Atrial Size

Resources for this article
• Margolese, R G, et al. Cancer Medicine (e.5 ed.). Hamilton, Ontario: B.C. Decker. ISBN 1-55009-113-1. Retrieved 27 January 2011.

• Allen NE, et al. (March 2009). “Moderate alcohol intake and cancer incidence in women”. Journal of the National Cancer Institute. 101 (5): 296–305. doi:10.1093/jnci/djn514.

• Lang RM, et al. “Recommendations for chamber quantification”. European Journal of Echocardiography. (2006) 7 (2): 79–108.  PMID 16458610. doi:10.1016/j.euje.2005.12.014. Retrieved 2012-08-26.

• Left atrial enlargement. Wikipedia, the free encyclopedia. Last edited 20 March 2018, https://en.wikipedia.org/wiki/Left_atrial_enlargement

FAQs: Normal or Enlarged Left Atrium—What does it Mean?

FAQs Understanding Your A-Fib A-Fib.comFAQs Understanding A-Fib: Enlarged Left Atrium

“How do I know if I have an enlarged left atrium and what does it mean, if it is? What is the size of a normal left atrium? 

When in A-Fib, your left atrium has to work harder than normal and tends to stretch and dilate over time. Obstructive sleep apnea (OSA) and high blood pressure can also contribute to an enlarged left atrium.

Consequences of an Enlarged Left Atrium: One study showed that Persistent A-Fib was associated with left atrium size (but not the number of years that a patient had A-Fib).

Left atrium size has been found to be a predictor of mortality due to both cardiovascular issues as well as all-cause mortality (although other factors may contribute).

As a result, some medical centers won’t do a Pulmonary Vein Ablation (Isolation) procedure if the left atrium is enlarged (over 5.5 cm). However, with the newer ablation techniques, other centers will. Surgeons also are reluctant to operate on someone with an enlarged heart.

Why You Need to Know Your Measurement: If you’ve had A-Fib for a while with significant symptoms, we often advise you to ask your doctor for this measurement to see if your left atrium is enlarged. This will be your benchmark for future comparison. It will be described in either centimeters (e.g. 2.0 cm) or millimeters (e.g. 20 mm).

Store this info with your other A-Fib test results and other papers in your A-Fib Binder or folder. Use the table below to rank the size of your atrium. (Reference note: 1 cm = 10 mm) Indexing the Left Atrial Size:

Women
Left AtriumNormalEnlarged
 mild moderatesevere
Diameter  (mm)27–3839–4243–46≥ 47
Volume  (ml)22–5253–6263–72≥73
Volume/BSA* 16–2829–3334–39≥ 40
Men
Left AtriumNormalEnlarged
 mild  moderatesevere
Diameter  (mm)30–4041–4647–52≥52
Volume  (ml)18–5859–6869–78≥79
Volume/BSA*16–2829–3334–39≥40

Note: Indexing the left atrial volume to body surface area* (BSA) is recommended by the American Society of Echocardiography and the European Association of Echocardiography. * BSA=body surface area.

Resources for this article
• Margolese, R G, et al. Cancer Medicine (e.5 ed.). Hamilton, Ontario: B.C. Decker. ISBN 1-55009-113-1. Retrieved 27 January 2011.

• Allen NE, et al. (March 2009). “Moderate alcohol intake and cancer incidence in women”. Journal of the National Cancer Institute. 101 (5): 296–305. doi:10.1093/jnci/djn514.

• Lang RM, et al. “Recommendations for chamber quantification”. European Journal of Echocardiography. (2006) 7 (2): 79–108.  PMID 16458610. doi:10.1016/j.euje.2005.12.014. Retrieved 2012-08-26.

• Left atrial enlargement. Wikipedia, the free encyclopedia. Last edited 20 March 2018, https://en.wikipedia.org/wiki/Left_atrial_enlargement

Back to FAQs: Understanding A-Fib 
Last updated: August 26, 2020

More FREE ‘Learn the Heart’ ECG Online Review Courses

Recently I posted about a FREE online course ‘ECG Basics‘ at Healio/LearnTheHeart.com designed to expand your understanding of Electrocardiograms (ECG or EKG) (see our description page).

More ‘Learn the Heart’ ECG Review Courses

This week I expanded the list of Healio ECG short courses that may be of interest to Atrial Fibrillation patients. Each includes examples of 12-lead ECGs and, where appropriate, specific criteria. Check out the following:

Illustration: Healio 'Atrial Fibrillation ECG Review‘

Illustration: Healio ‘Atrial Fibrillation ECG Review‘

Atrial Fibrillation ECG Review
Atrial Flutter ECG Review
Premature Atrial Contractions (PACs) ECG Review
Left Atrial Enlargement (LAE) ECG Review
Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review

ECG Quizzes, Too

You can also challenge yourself with the Beginner ECG Quiz featuring detailed answers and links to pertinent explanation pages. Or test your overall knowledge of Atrial Fibrillation with a multiple choice Atrial Fibrillation Quiz.

Steve’s Brief Overview: The EKG Signal

If you want just a brief overview of the ECG waveform signal and how to “read” an ECG tracing, go to my report, Understanding the EKG Signal.

Learn to Read Your ECG: Free Online Self-Paced Courses at Healio.com

Start with the ‘ECG Basics’ course

For the reader wanting a more extensive understanding of the Electrocardiogram and A-Fib, we offer you a link to Healio Learn the Hearta FREE online cardiology resource for those seeking to increase their knowledge of ECG tracings interpretation and cardiovascular diseases.

‘Learn the Heart’: A Review or ECG Basics

I suggest you start with the ‘Atrial Fibrillation ECG Review‘ then move on to the ‘ECG Basics‘ to analyze each part of the ECG tracing. Included are detailed explanations and ECG images of the heart in Atrial Fibrillation.

The ‘ECG Basics‘ is concise and focused on only what you need to know, yet very thorough — from waves to segments to complexes. On the LearnTheHeart.com website:

⇒ Go to the Atrial Fibrillation ECG Review->
⇒ Go to the ECG Basics training module->

Reviews and Quizzes, Too

Healio ‘Atrial Fibrillation ECG Review‘ ECG graphic

You can even challenge yourself with the Beginner ECG Quiz featuring detailed answers and links to pertinent explanation pages. Or test your overall knowledge of Atrial Fibrillation with a multiple choice Atrial Fibrillation Quiz.

Other ‘Learn the Heart’ ECG Review Courses

Other ECG courses from Healio review all common ECG findings including normal and abnormal. Each review includes example 12-lead ECGs and, where appropriate, specific criteria. Of particular interest to Atrial Fibrillation patients may be:

Atrial Flutter ECG Review
Premature Atrial Contractions (PACs) ECG Review
Left Atrial Enlargement (LAE) ECG Review
Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review

Steve’s Brief Overview: The EKG Signal

If you want just a brief overview of the ECG waveform signal and how to “read” an ECG tracing, go to my report, Understanding the EKG Signal.

When Tracking Your Heart: Is a Wrist-Worn Heart Rate Monitor Just as Good as a Chest Strap Monitor?

Wrist-worn heart rate fitness trackers like Fitbit and Apple Watch have become trendy wrist accessories, but are they accurate enough for Atrial Fibrillation patients? How do fitness trackers compare to chest strap heart rate monitors (HRMs)?

What’s Behind the Discrepancies? Different Technologies

Chest-band HRM transmitted to wristwatch

Chest strap style heart rate monitors are consumer products designed for athletes and runners, but used by A-Fib patients, too. They measure the electrical activity of the heart. They’re usually a belt-like elastic band that wraps snugly around your chest with a small electrode pad against your skin and a snap-on transmitter.

The pad needs moisture (water or sweat) to pick up any electrical signal. That information is sent to a microprocessor in the transmitter that records and analyzes heart rate and sends it to a wrist watch display or smartphone app.

Optical HRM with LEDs on inside

Wrist fitness trackers typically sit on your wrist and don’t measure what the heart does. Most glean heart-rate data through “photoplethysmography” (PPG) with small LEDs on their undersides that shine green light onto the skin on your wrist.

The different wavelengths of light interact differently with the blood flowing through your wrist, the data is captured and processed to produce understandable pulse readings on the band itself (or transmitted to another device or app).

HRMs Research Study

A 2016 single-center study was designed to find out whether wrist-worn heart rate monitors readings are accurate. Four brands of fitness trackers were compared against the Polar H7 chest strap heart monitor (HRM) and, as a baseline, with a standard electrocardiogram (ECG).

On a personal note, I used a Polar-brand chest-band monitor when I had A-Fib, and that’s what I recommend to other A-Fib patients.

Researchers at the Cleveland Clinic enrolled 50 healthy adults, mean age, 37 years. In addition to ECG leads and the Polar chest-band heart rate monitor, patients were randomly assigned to wear two different wrist-worn heart rate monitors (out of the four).

Participants completed a treadmill protocol, in which heart rate was assessed at rest and at different paces: between two and six miles per hour. Heart rate was assessed again after the treadmill exercise during recovery at 30 seconds, 60 seconds and 90 seconds.

In total, 1,773 heart rate values ranging from 49 bpm to 200 bpm were recorded during the study. Accuracy was not affected by age, BMI or sex. The four wrist-worn heart rate monitors assessed were the Apple Watch (Apple), Fitbit Charge HR (Fitbit), Mio Alpha (Mio Global) and Basis Peak (Basis).1

HRMs Study Results

Chest Strap Monitors: The chest strap monitor was the most accurate, with readings closely matching readings from the electrocardiogram (ECG).

The chest strap monitor was the most accurate, closely matching the ECG; The wrist-bands were best when the heart was at rest.
In general, the chest straps were more accurate because the sensor is placed closer to the heart (than a wristband), allowing it to capture a stronger heart-beat signal.

Wrist-Worn Monitors: Accuracy of wrist-worn monitors was best at rest and became less accurate with more vigorous exercise, which presumably is when you’d most want to know your heart rate.

None of the wrist-worn monitors achieved the accuracy of a chest strap-based monitor. According to the electrocardiograph, some wrist-worn devices over- or underestimated heart rate by 50 bpm or more.

What Patients Need to Know

Blue-tooth chest-band with smartphone app at A-Fib.com

Blue-tooth chest-band with smartphone app

Wrist-band optical heart-rate monitors may be more convenient or comfortable and have advanced over the years. But in this small study, researchers found that chest-strap monitors were always more accurate than their wrist counterparts and more reliable and consistent.

When monitoring your heart beat rate is important to you (while exercising or doing heavy work), you’ll want to stick with an electrode-containing monitor (chest band-style, shirts or sports bras with built-in electrode pads, etc.).

To help you choose a HRM, see Steve’s Top Picks: DIY Heart Rate Monitors for A-Fib Patients at Amazon.

Bottom line 
Leave the wrist-worn trackers for the casual fitness enthusiasts

References for this Article
• Accuracy of popular wrist-worn heart rate monitors varies during exercise. Cardiology Today. Healio.com. October 19, 2016. http://tinyurl.com/Healio-Wrist-Worn-Monitors

• Safety Recall of Basic Peak Watch, Sept. 16, 2016: http://www.mybasis.com/safety/

• Wang R, et al. Accuracy of popular wrist-worn heart rate monitors varies during exercise; JAMA Cardiology. 2016;doi:10.1001/jamacardio.2016.3340. October 19, 2016

• Phend, C. Wrist-Worn Heart Monitors Unreliable During Exercise: Popular devices don’t stand up to ECG. MedPage Today. October 12, 2016. http://www.medpagetoday.com/cardiology/prevention/60751

• Ross, E. You Can Monitor Heart Rhythm With A Smartphone, But Should You? NPR.org. October 15, 2016. http://tinyurl.com/NPR-wrist-heartratemonitors.

• Margolin, M. Your Heart Rate Monitor Is Nonsense, Study Says. Oct 18 2016. https://motherboard.vice.com/en_us/article/your-fitbit-heart-rate-monitor-wrong-cardiology

• Palladino, V. How wearable heart-rate monitors work, and which is best for you. The choice between chest straps and optical monitors is more complex than it seems. Ars Technica 4/2/2017. https://arstechnica.com/gadgets/2017/04/how-wearable-heart-rate-monitors-work-and-which-is-best-for-you/

Footnote Citations    (↵ returns to text)

  1. Safety Recall of Basic Peak Watch, Sept. 16, 2016: http://www.mybasis.com/safety/

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

AF Symposium 2015

Sébastien Knecht PMD PhD

AFACART Clinical Trial: Preliminary Results of the CardioInsight—ECVUE System in Multiple Centers

By Steve s. Ryan, PhD, July 2015

Pr. Sebastian Knecht from CHU Brugmann, Brussels, (now AZ Sint Jan, Brugge), Belgium gave a presentation entitled “AFACART Trial—Design and Preliminary Results.” (AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI).

Introduction

In preparation for their ablation the patient dons the ECGI vest-like device. The data generated creates an image of the heart and pinpoints sites (“drivers”) producing A-Fib signals. This 3-D computer model of the patient’s heart is used during the ablation procedure.

AFACART Clinical Trial Design and Participants

The AFACART trial is a European multicenter, feasibility, non-randomized study using “Panoramic Electrographic Non-Invasive Mapping”, specifically the CardioInsight—ECVUE System, for ablation of persistent A-Fib. 

AFACART stands for “Non-Invasive Mapping of Atrial Fibrillation,” a new name for ECGI

Ablation patients are to be followed for 12 months. The effectiveness of Panoramic Electrographic Non-Invasive Mapping is to be compared to conventional mapping and ablation procedures.

Eight European centers in France, Belgium and Germany are participating in this clinical trial. None of these centers had any practical experience with this system before this study.

Ablation Steps One to Three

In an important change to standard ablation procedures, the first step in the ECGI/ECVUE ablation process is ablation of A-Fib drivers (rotors and foci).  (This is in comparison to the step-wise approach that begins with ablation of the pulmonary vein openings.)

If A-Fib doesn’t terminate to sinus rhythm or stable atrial tachycardia isn’t achieved (> 5 min), then a standard PVI is performed.

This is followed by linear lesions. And finally by Electrocardioversion.

AFACART Trial Preliminary Results

• Step One (driver ablation only): 64% of the persistent A-Fib patients had their A-Fib terminated.
• Step Two (driver and PVI ablation): 66% termination
• Step Three (driver, PVI, and LA linear lesions) 73% termination

For our technical readers, Dr. Knecht defined ‘drivers’ as “local reentrant circuits (> 1.5 rotations) or focal breakthroughs (>2) that appear at the same spatial location per window.”

In 94% of patients, driver ablation had a significant impact on the A-Fib termination process. A-Fib cycle length was prolonged in all persistent patients except for 6%. Even patients who were not terminated (27%) had their A-Fib cycle length prolonged by driver ablation.

After 12 months, 72% of patients were A-Fib free and no longer taking antiarrhythmic meds (AADs). 31% had Atrial Tachycardia recurrence, but many had a second ablation.

Overall 83% were A-Fib free, 17% had Atrial Tachycardias and only 9% were still in A-Fib.

Ablation procedure time averaged only 44.7 minutes. As the number of driver regions increased, the ablation success rate decreased. 66% of drivers were in the Left Atrium, 34% in the right. 70% of termination sites were in the left atrium, 30% in the right.

Driver Sites and CFAEs

• In these persistent A-Fib patients, 50% of both atria had CFAEs.
• Most (but not all) driver sites contained CFAEs.
• Successful driver ablation only ablated 19% of both atria (this is a major improvement and resulted in much less ablation damage to the heart compared to trying to ablate all CFAE areas).

Dr. Knecht stated that “use of the ECVUE system seems to result in a more specific selection of CFAEs leading to a more targeted ablation strategy.”

Dr. Knecht’s Conclusions

Ablation of A-Fib drivers is associated with a high rate of A-Fib termination.

• Drivers are distributed in both atria (2/3 LA and 1/3 RA).
• Results are reproducible among centers without prior practical experience with the system.
• Preliminary chronic results are very promising.

Editor’s Comments:
Driver Ablation More Important Than PVI in Persistent A-Fib: ECGI is changing the way ablations are done and our understanding of A-Fib. In persistent A-Fib, the mapping and ablation of drivers is more important and is done before a PVI ablation. While driver ablation had a 64% success rate, doing a standard PVI after driver ablation only improved results by 2%.
ECGI/ECVUE Major Improvement in Ablation Success Rate: An 83% success rate after 12 months following ablations for tachycardias, is a major improvement and source of hope for persistent A-Fib patients. These results were even better when one considers that only 9% were still in A-Fib.
ECGI/ECVUE Results in Much Fewer Ablation Burns: Previous protocols for ablating persistent A-Fib usually involved mapping and ablating CFAEs. But CFAEs in persistent A-Fib patients can cover 50% of the atria surfaces which often necessitated a lot of burns and debulking.
Too many ablation burns could result in the development of fibrosis (dead heart tissue where the ablation catheter produced burns and scarring) and a stiffening of the atria with loss of pumping ability. ECGI/ECVUE only requires ablating 19% of the CFAE areas resulting in much less lasting damage to heart tissue.
Driver Ablation Prolongs A-Fib Cycle Length: Driver ablation had a major effect on the A-Fib termination process. A-Fib cycle length was prolonged in all but 6% of the persistent A-Fib patients. This is perhaps a first step in improving outcomes for persistent A-Fib patients.
Reproducibility: The most important finding of Dr. Knecht’s report is that ECGI/ECVUE works in other centers without doctors (operators) having to undergo extensive training.
These preliminary results from this multi-center clinical trial are quite impressive for the treatment of patients with persistent A-Fib. Hopefully it won’t be long before the ECGI/ECVUE system is available in more countries. (ECGI was invented at Washington Un. in St. Louis, MO and is available there on a limited basis.)

To learn more about ECGI, see Non-Invasive Electrocardiographic Imaging (ECGI): Presentation Summary and Comments from the 2013 AF Symposium. You may want to read this report in conjunction with Dr. Haissaguerre’s 2015 AF Symposium presentation The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques.

References for this article
Non Invasive Mapping Before Ablation for Atrial Fibrillation: THE AFACART STUDY. ClinicalTrials.gov Identifier: NCT02113761. Sponsor: Brugmann University Hospital. Responsible Party: Pr Sébastien Knecht, PMD PhD, Brugmann University Hospital. URL: https://clinicaltrials.gov/ct2/show/NCT02113761

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Last updated: Friday, January 1, 2016

Persistent A-Fib: ECGI Insights to Finding Additional Drivers by Dr Jais

AF Symposium 2015

Pierre Jais MD

Pierre Jais MD

Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions

By Steve s. Ryan, PhD, July 2015

Dr. Pierre Jais of the French Bordeaux/LIRYC group gave a presentation on “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”

He described a study of the ablation of 50 persistent A-Fib patients using ECGI to map and ablate A-Fib signal drivers.

A-Fib was terminated in 79% of patients, with 10% returned to sinus rhythm and the remaining 69% in tachycardias (but with no A-Fib).

For those still in arrhythmia, ECGI was used to map, analyze and diagnose the locations of the arrhythmias signals, and additional ablation lesions were performed. Identified were 25 macro-reentry circuits and 14 focal/localized-reentry circuits.

The reentry circuits found by ECGI were:

• common atrial flutter in 14 patients
• perimitral flutter in 9 patients
• roof dependent flutter in 2 patients

Dr. Jais showed many slides and videos of how ECGI mapped and analyzed where these arrhythmias were coming from and how they were ablated.

Dr. Jais’ Conclusions

Dr. Jais stated that the study data revealed, “the focal/localized-reentry were adjacent to drivers at 0.9cm from the core of driver with low voltage (0.5 mV)”.

To clarify, this means that the drivers of the remaining arrhythmias were located very close (adjacent) to the drivers previously mapped by ECGI.

Therefore, when ECGI locates an area of rotors and drivers, it is highly likely this is where the source of additional arrhythmias will most likely be found. This insight reduces or eliminates the need (and time) to search other areas of the heart thereby shortening procedure length and decreasing the number of lesions needed.

Editor’s Comments:
ECGI mapping and ablating is changing our understanding of and our techniques for ablating persistent A-Fib. If a patient has continued arrhythmias after the initial ablation, ECGI often can re-map and identify where the remaining arrhythmias are coming from, usually very near previously identified driver locations. This is a valuable insight for doctors doing ablations.
For patients, it may mean a shorter procedure time with fewer burns needed to eliminate the sources of A-Fib signals.

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Last updated: Thursday, August 6, 2015

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

Dr Michele Haïssaguerre, The French Bordeaux group/LIRYC

AF Symposium 2015

The Changing Ablation World: Going Beyond PVI With ECGI Mapping and Ablation Techniques

By Steve S. Ryan, May 2015

ECGI is changing everything—not only the way mapping and ablations are done, but also our basic understanding of A-Fib. Instead of potentials and CFAEs, EPs will focus on ablating drivers (rotors and foci). Ablating the PVs will still be basic. But in more difficult cases, EPs must look for non-PV triggers or drivers.

Prof. Michel Haïssaguerre of the French Bordeaux group/LIRYC gave a presentation entitled “Beyond PVI—Mapping and Ablation Techniques for Elimination of Drivers in Persistent AF.” Non-Invasive Electrocardiographic Imaging, or ECGI (from CardioInsight) is a radically new and innovative mapping and ablation system.

The ECGI Vest-Like Device Innovative Mapping and Ablation System

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

Dr. Haïssaguerre patient, Carlo Romero, as technician attaches ECGI vest

The day before their ablation, the patient lies down on their back and a technician places a vest-like device with 256 electrodes over their chest and stomach. These electrodes combine with rapid CT (Computed Tomography) scans to produce a very detailed 3D color map of the heart.

The system automatically detects rotors and foci and computes them into a “Cumulative Map” or movie. These driver regions are ranked, based on statistical prevalence. They are displayed in statistical density maps which define the ablation roadmap.

The use of ECGI mapping results in a drastic decrease of RF burns needed
The ECGI vest doesn’t directly record A-Fib signals from the septal regions. But Dr. Haïssaguerre showed slides where the septal drivers project onto the anterior and posterior attachments of the septum and are thus able to be mapped. For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging (ECGI).

Ablation using ECGI results in a drastic decrease of RF burns needed to produce A-Fib termination.

In ECGI, Paroxysmal and Persistent A-Fib Ablation are Different

Paroxysmal: Using ECGI in 41 paroxysmal patients, Dr. Haïssaguerre found that the A-Fib drivers originated from the PV/post LA region. They consisted of PV discharges interacting with short-lived ostial rotors, which is in accordance with current knowledge and practice of A-Fib ablation. (A standard PVI ablation normally targets these areas.)

Persistent: But in 248 persistent A-Fib cases (54% with Structural Heart Disease), he found multiple interplaying A-Fib drivers coming from both atria but usually clustered in 4 regions. (The regions could vary from 1-7.) These drivers were short lived (3-4 reentries/firings) but periodically recurred in the same areas. As one would expect, the number of driver regions increased with the duration of persistent A-Fib. Long-Lasting persistent had 7 driver regions diffused throughout the atria. Cases with only 1 driver region were rare (9%).

Relationship of Drivers and CFAEs

These driver regions overlapped with areas of CFAEs (Complex Fractionated Atrial Electrograms). But whereas CFAEs were found in 49% of the total atrial surface, drivers were found only in 19%. Also, fractionated signals were more frequent and spanned a greater part of the A-Fib cycle length in driver regions than elsewhere (71% vs 47%). (This is good news for patients with persistent A-Fib. With ECGI, much less heart area needs to undergo ablation burns.)

Best Ablation Outcome is A-Fib Termination, But Not Always Possible with Persistent A-Fib

Dr. Haïssaguerre showed slides where he ablated driver regions which transformed rapid complex A-Fib signals into slower organized signals. He stated from his own experience and from several studies that the best outcome of ablation was A-Fib termination into sinus rhythm or tachycardia.

But this result was much harder to achieve in long-lasting persistent A-Fib. In cases where patients had only recently went into persistent A-Fib (1-3 months), 75% had A-Fib termination targeting driver regions. While in long-lasting persistent A-Fib, only 13% had A-Fib termination. Dr. Haïssaguerre’s hypothesis was that early persistent A-Fib is initially driver-dependent, while long-lasting persistent cases progress to widespread substrate disease.

In another study following 90 patients, 85% of patients with A-Fib termination were A-Fib free after 12 months (in the remaining 15%, 54% were paroxysmal). While patients who didn’t have their A-Fib terminated, only 63% were A-Fib free (all were persistent).

What EPs Do When AF Persists After ECGI Driver Ablation

• Check driver regions (including PVs) to ensure abolition of rapid-disorganized EGMs (electrogram signals).

• Body Surface Remapping—to look for new drivers appearing after the first ones are eliminated. Many have observed that this strategy often improves results in difficult cases of long-lasting A-Fib.

Right Atrium Ablation

Dr. Haïssaguerre recommended ablating the right atrium after the left. Right atrium drivers can disappear after left atrium ablation.

Dr. Haïssaguerre’s Conclusions

• Noninvasive mapping visualizes AF drivers which are Multiple, Meandering, ShortLasting and Associated with Complex EGMs (electrogram signals).

• Ablation targeting these AF critical regions allows high rate of AF termination with minimal RF delivery.

• 85% AF freedom at one year when procedural AF termination is achieved.

• Reproducibility in 8 centers in Germany, Belgium and France (AFACART) (Eight centers in Europe are now performing ECGI ablations with similar results.)

Editor’s Comments:
Non-PV Triggers: If your EP only ablates the PVs, you should look elsewhere. I just read an O.R. (Operating Report) where the EP only CryoBalloon ablated the PVs. Even though the patient was still in A-Fib after the PVs were ablated, the EP didn’t look for non-PV triggers. He simply shocked the patient back into sinus rhythm and put him on an antiarrhythmic drug. Chances are the patient’s A-Fib will return, since the non-PV triggers in his heart weren’t ablated.
Driver regions overlap with CFAEs—CFAEs can be ignored: In difficult cases of A-Fib, EPs used to spend a lot of time mapping and ablating CFAEs. Sometimes there were so many CFAEs that the EP wound up debulking much of the left atrium. In Dr. Haïssaguerre’s research, CFAEs could cover nearly half of the total atria surface. But with ECGI, only 19% of that area is ablated. ECGI makes the EP’s job simpler and causes less burns on the patient’s heart.
Try to Get Out of Persistent A-Fib: If you haven’t done so already, ask your EP to be Electrocardioverted in order to avoid long-lasting A-Fib which causes atrial remodeling that produces widespread fibrosis and diffuse driver regions.
You may want to try the newer antiarrhythmic drug Tikosyn (dofetilide) which works well in some cases of persistent A-Fib. (When starting Tikosyn, you will have to be hospitalized for three days to get the dosage right and to check for bad side effects.)
Currently some long-standing A-Fib can’t be cured: The best outcome of ablation is A-Fib termination. But some long-lasting persistent cases turn into widespread substrate disease where it’s not always possible to map and ablate drivers. Even the famed Bordeaux group hasn’t yet figured out a way to achieve 100% success when ablating all long-standing persistent A-Fib.
If you have long-standing persistent A-Fib, should you just throw in the towel and give up? No. In Dr. Haïssaguerre experience, 63% of persistent patients who didn’t have their A-Fib terminated were still A-Fib free. You could be in that 63%. Just be realistic and don’t expect miracles.

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Last updated: Saturday, May 30, 2015

DIY Heart Rate Monitors: How They Work For A-Fib Patients (Part II)

Polar Heart Rate Monitors

Go to: DIY Heart Rate Monitors

by Steve S. Ryan, PhD

A-Fib patients sometimes use consumer ‘DIY” Heart Rate Monitors (HRM) when exercising or performing physically demanding activities (For specific models and options, see our article, DIY Heart Rate Monitors & Handheld ECG Monitors Part I.)

How Do DIY Heart Rate Monitors Work?

Basic HRMs use a chest strap to pick up the electrical signals from the heart. However, due to the inherent design of the chest strap, the accuracy is somewhat limited and is no replacement for the signals recorded by a Holter or Event Monitor.

Heart-Rhythm-Monitors-EKG - 325 pix wide at 96 resA HRM keeps track of your heart’s R-R interval or the time between R peaks. Without getting too technical, the R peak on a generic ECG waveform (see the diagram) corresponds to the ventricle beat (depolarization) and has the largest amplitude (height) of the complete waveform.

When the amplitude (picked up as a voltage differential) exceeds a certain threshold, a “beat” is picked up by the chest strap and transmitted wirelessly to the HRM. It is the time between these R peak “beats” that is used by the HRM to determine instantaneous heart rate. It is only going to pick up episodes of arrhythmia as are manifested in ventricle beats (the R on the waveform).

Learn more about the EKG signal, see Steve’s article: Understanding the EKG (ECG) Signal.
So if your arrhythmia manifests itself in funky R activity (higher than normal rate) you will see a corresponding readout on the HRM. In this same light, an irregular or unevenly spaced R peaks will not be picked up by the HRM.

This is one of the fundamental differences in how data is recorded by HRMs (R-R interval) versus Holter/Event Monitors (actual waveform).

In fact, this is what Polar has to say:

“Polar products are not designed to detect arrhythmia or irregular rhythms and will interpret them as noise or interference. The computer in the wrist unit will make error corrections, so that arrhythmia beats are not included in the averaged beats per minute. The blinking heart symbol in the face of the unit, however, will continue to show all heart beats received.

In most cases the Polar products will work fine for persons with arrhythmia.”

Example PC interface capability of a Polar PC program.

Graphic example PC interface capability of a Polar PC program.

HRM Recording Capability

Most HRMs provide some internal storage recording capability. While lower cost HRMs simply record low, high and average heart rate, upper end models allow you to download heart rate data to your PC.

App-enabled smartphones are changing how this data is viewed, collected and saved for future review.

How To Setup and Use an HRM

On most of the HRMs, you can set a heart rate zone, and the watch monitor (or app-enabled smartphone) will record how long you stayed in that zone.

You could then program a high heart rate zone which you might only enter if you were in A-Fib. That way you could record how long you stayed in A-Fib and what your max heart rate was. This data could be reviewed on the watch monitor (or app-enabled smartphone) without having to download it to a PC.

On HRMs with PC interface capability, you can view data in a graphic form (on some watches/smartphones you can view the graphic data but with lower resolution.) This analyses could tell you when you were at a higher heart rate—A-Fib—and how long you stayed there. Of course these kinds of features require some PC skills, but typically the programs are pretty user friendly. (See the above graphic example of a Polar PC program).

For more, see our article, DIY Heart Rate Monitors & Handheld ECG Monitors.

Shop Amazon.com for Steve’s Top Picks: DIY Heart Rate Monitors for A-Fib Patients.

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If you find any errors on this page, email us. Y Last updated: Monday, August 27, 2018

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