Good afternoon. I'm just going to start with a few quick, quick housekeeping items. I know you're all experts now at using your app, but just a reminder to open the session and the Q&A button would be at the bottom. So if you are going to ask questions, make sure you have that open. And we'll go ahead and get started here to keep us on time. Welcome to our session on AFib ablation. I know we did have an earlier session for AFib ablation track, and I don't know if many of you were in that track, but I'd like to make some quick introductions to our moderator and to our presenter for today. First let me introduce our moderator, Sarah Lash, if you were in our earlier AFib session. Sarah is our new product manager for AFib ablation registry, the EP device implant registry, and the new CVASC, or outpatient registry, which is collecting information on EP procedures as well as cath interventions. So we welcome Sarah to Quality Summit, and we are excited to have her in this new role. She's been with the ACC for three years now. And it's a pleasure to have you all here with us today. I want to thank you for all the work that you do in advancing quality and helping us better understand what's happening to our patients, and all the work that you do, all the effort that you put in to improving the care. So thank you very much. You all should give yourselves a big applause, or we'll applaud you. You do a lot of hard work. And without further ado, I'd like to introduce Dr. Suzuki. He's here with us from Indiana, and we are very pleased to have him with us. He is also a steering committee member on our EP registry suite steering committee, so he gives us expertise and guidance in many ways. And he is here today to share that expertise with you and talk about our newest AFib guidelines that came out. So welcome, Dr. Suzuki. Thank you. Well, good afternoon. Christina and Sarah, thank you very much for the introduction, and my name is Takeki Suzuki. Thank you very much for the opportunity to talk to you. This is a first, like a day, but it's a late session, so thank you very much for being here. I'm pretty sure that you're a little tired, but I think we'll get started. I hope it's okay. Okay. Okay. So today... Oh, I see. Okay. Okay. So today, my topic is atrial fibrillation. As you remember, we had a new guideline published later last year, 2023. There are some updates, and I think it's a great idea to get some updates in the AF guideline. I know our main focus is ablation, but I think AF itself is a very, very important condition, so I think I'm very, very happy to talk to you about this lecture. So, learning objectives of this talk. So, first, I want you to identify top take-home messages for the 2023 AF guideline. Number two, learn the new stages of atrial fibrillation. And number three, review plus-one indications for catheter ablation. So, these are kind of, you know, like something that you will learn, I think, at the end of this talk. But again, you know, like, atrial fibrillation is a big topic. I mean, it's very, very simple, but if you look at these guidelines, there are so many guidelines, like going back, you know, like 2006, 2011, you know, HRS, you know, like ACC, ESC, and this is the most recent update from 2019 before the most recent guideline. But either way, so many guidelines. But also, you know, if you are familiar with these guidelines, you know, there is a new guideline from ESC or European Society of Cardiology, but I will focus on this, you know, like our guideline. So, this is our focus today. So, coming back to the baseline, so what is atrial fibrillation? I mean, it's a very, very simple, but, you know, very, very, you know, kind of broad question. So, atrial fibrillation is the most common sustained cardiac arrhythmia, and looking at EKG, you can look at irregular RR intervals, and also if you look at, you know, like EKG, there is no P wave. You know, we love P wave, you know, as a, you know, like an electrophysiologist, but, you know, we don't have P wave in, you know, somebody with atrial fibrillation, and, you know, it has irregular atrial activity. I mean, you know, it's kind of, you know, difficult to, you know, like imagine what it is, but if you look at this EKG, I mean, this is something that you see, you know, like a daily practice. I mean, atrial fibrillation, you know, very common in the heart rhythm, you know, disorder, and I'm very, very sure that you see, you know, every day. But anyway, so I think the first point is the definition of atrial fibrillation. So, this is a prior guideline definition from 2014. So, as we know, you know, like atrial fibrillation, you know, definition is purely based on the duration of atrial fibrillation, meaning that, you know, like if, you know, atrial fibrillation is within seven days, we call that paroxysmal atrial fibrillation, just because, you know, it's, you know, like, you know, paroxysmal, and it lasts only, you know, less than one week. And if it lasts for longer than one week, it is called or defined as persistent atrial fibrillation. And, you know, if, you know, a patient is in AFib for a long time, let's say, you know, like one year, you know, we call, you know, that kind of AFib as longstanding persistent AFib. You know, as you see, you know, these are purely based on the duration of atrial fibrillation. And also, you know, like, as you know, you know, permanent atrial fibrillation is used when patient and clinician make a joint decision to stop, like, attempts to restore or maintain sinus rhythm. So, meaning that, you know, there are some people who is in, you know, atrial fibrillation for a long time, and, you know, like, you know, like sometimes we have difficulty controlling heart rhythm, and that kind of we talk, and we say, you know, like, let's, you know, focus more on rate control rather than the rhythm control. That's, you know, when we, you know, like call this kind of, you know, atrial fibrillation as permanent atrial fibrillation. But, you know, this is a kind of, you know, like something that we know from before. And also, by the way, this upgrade, update from 2019, you know, valvular atrial fibrillation was defined as moderate to severe mitral stenosis or mechanical heart valve. That's from prior, you know, update. But either way, this is a kind of old story. So, this is a new kind of, you know, like AF classification from the new guidelines. So, very, very important. You know, now we have four stages of atrial fibrillation. So, looking at, you know, these, you know, stages, you know, like, you know, stage one, two, and three, and four, actually stage three is something that, you know, I was talking to you. This is something that we know, you know, like about, you know, like paroxysmal, persistent, long-standing persistent, or, you know, like, or, you know, these kind of, you know, like, you know, definition. But here, you know, like as we have, you know, catheter ablation, we got the new addition to the, you know, category here. It's 3D. That's, you know, successful AF ablation. So, it's, you know, stage 3D is, you know, somebody who got atrial fibrillation ablated and in sinus rhythm, you know, successful ablation. You know, that's kind of a new, you know, like category. But I think, you know, more important thing is, you know, like one and two, you know, like stages, first stage and second stage, I think this is the most important thing. You know, like this is similar to heart failure, you know, like a category, you know, like stage one is like at risk for atrial fibrillation, meaning that, you know, they do not have atrial fibrillation, but they may have some modifiable or non-modifiable risk factors like obesity, you know, physical inactivity, hypertension, sleep apnea, or alcohol use or diabetes. This is somebody who do not have atrial fibrillation, but who may, you know, need to, you know, adjust risk factors to prevent them from having atrial fibrillation. So, kind of like a, you know, broader spectrum of patients, you know, in this kind of, you know, new classification. And also, you know, like, you know, stage two is pre-AF. That means, you know, there are somebody who got some structural or electrical finding further, you know, predisposing a patient to atrial fibrillation, meaning that we know that if, you know, you have, you know, dilated atrium, you may have higher chance of having atrial fibrillation, or you may have, you know, like ectopy, like PSEs, that may put you at higher risk for having atrial fibrillation. So, this is kind of, you know, like a pre or, you know, like at higher risk for, you know, AFib patients. So, other caveat is, you know, look at, you know, these what, you know, we can do. So, like for this, you know, like a stage, from stage one, you know, like we can start, you know, treating modifiable risk factors. The stage two, you know, like, you know, surveillance is something that you may want to consider. So, this is a kind of new, you know, like classification, and I think I really want you to keep this in mind when you go home. So, again, you know, four stages of atrial fibrillation. Kind of, you know, like, again, you know, like a similar, but, you know, like a stage one, you know, treating, you know, risk factors and, you know, going to pre-AF. There's, you know, more, you know, surveillance. And the stage three is more like conventional atrial fibrillation, but each stage has, you know, it's kind of a strategy. So, I think, you know, this is, you know, really important. And also, you know, like this, you know, like shows that, you know, atrial fibrillation is actually a disease continuum. You know, this is, I mean, you know, heart rhythm issue, but actually, you know, this is a continuum, and, you know, it's kind of, you know, like a progressive disease. You know, like that's, you know, basically what this means. So, a little bit about atrial fibrillation. So, as I mentioned, you know, like atrial fibrillation is the most common sustained cardiac arrhythmia. It affects, you know, like 5.2 million Americans in 2010, and expected to increase up to 12.1 million in 2030. And globally, you know, like 52 million individuals have atrial fibrillation and atrial flutter in 2021. It's a big public issue. And from lifetime risk of atrial fibrillation, lifetime risk of atrial fibrillation is estimated to be like a 36% in white male and 30%, you know, like in white females. And the black, you know, males, it's 22%, and the black females, sorry, yeah, like 21% and 22% in black, you know, males and females. And lifetime risk for atrial fibrillation looks like a little smaller in Asians. This is a report from Taiwan, and, you know, Asian males have 16.9% lifetime risk of atrial fibrillation, and 14.6% in Asian females. Either way, so that's a, you know, big public, you know, issue. And this is, you know, like a, you know, something that kind of, you know, like a very, very simple treatment goals and strategies, you know, like from old days. I would say this is from, you know, 10 years ago or, you know, even like a long time ago. And, you know, it used to be atrial fibrillation management used to be very simple. You know, like what we do is weight control, the maintenance of sinus rhythm. You know, these are, you know, anti-arythmic drugs, and stroke prevention. I mean, this is something that have been, you know, around for a long time. And kind of, you know, simple, you know, like in old days. But, you know, things are getting, you know, more comprehensive and, you know, like it's getting, you know, more things that we can do for atrial, you know, patients with atrial fibrillation. This is, you know, pillars for AF management. So I think, you know, like this, you know, like you can, you know, take a look from the foundation. So, again, foundation is to treat risk factors and enact behavioral changes. And they come up with a nice, you know, like a saying, you know, head to toes. It's a kind of, you know, like a very, I like this. But basically, you know, like, you know, treating heart failure, exercise, atrial hypertension, diabetes, and tobacco, obesity, like ethanol or alcohol or sleep. This is kind of, you know, like, you know, risk factors, you know, for atrial fibrillation. And also, you know, like here, you know, you have shared decision making. So treating or, you know, like seeing patients with atrial fibrillation is like almost like, you know, like talking with a patient and, you know, to make a, you know, shared decision. That's kind of, you know, very, very important aspect in patient care. And after this, we have called, now it's called SOS. It's kind of, you know, like, you know, interesting. Stroke risk and optimize all modifiable risk factors and symptom management. So that's kind of, you know, like three major pillars for AF management. Lastly, you know, like access to all aspects of care for all. So we hope to, you know, achieve access to all aspects of, you know, care for all AF patients. That's kind of, you know, like a very, very, you know, comprehensive, you know, way of, you know, looking at, you know, like AF, you know, management. So let me start with, you know, optimize like all part of SOS. Optimize all modifiable risk factors. So what that means. So I think, you know, like we basically, you know, like address risk factor for management of atrial fibrillation. We have found out that, you know, these are, you know, like, you know, it's called, you know, like cardiovascular risk factors are actually, you know, like, you know, risk factors for atrial fibrillation. So, you know, like weight management, hyperlipidemia, sleep apnea, hypertension, diabetes, and smoking and alcohol cessation. These are kind of things, you know, that we do, you know, before, you know, like ablation procedure or, you know, any, you know, procedure or interventional procedure can be done. And this is very, very important. So let me introduce two studies, you know, regarding risk factor management. The first one is called Legacy Study. By the way, these, you know, two studies are from Australia. And the first, you know, Legacy Study enrolled patients with BMI over 27 on atrial fibrillation. And what they did was they did a weight management and they followed patients for five years. And they divided participants into three groups. And group one is somebody who lost weight over 10%. And group two is like an intermediate. And group three is, you know, very, very minimal weight, you know, change. So what they did was they enrolled 355 patients. What they showed was weight loss and weight fluctuation were independent predictors of outcome. You know, the outcome is basically looking at burden and symptoms. You know, like this is, you know, Kaplan-Meier curve. You know, looking at this, you know, this is somebody with, you know, good, you know, like weight management or, you know, like more than 10% weight reduction. This group is shown to have the better, you know, like outcome regarding AF recurrence compared to other groups. So from this, you know, study, so this is the most current guideline recommendation. So they gave, you know, like a class one recommendation, you know, for weight management in somebody with overweight. The weight management is to reduce atrial fibrillation symptoms, burden, and recurrence. And also, you know, it is shown to decrease progression to persistent atrial fibrillation. So this is a class one recommendation. So the second study that I wanted to talk to you in this, you know, risk factor management is AREST-AF cohort study. Again, this is from Australia. So what they did was they enrolled patients undergoing AF ablations. Again, overweight, over 27 BMI, not within, you know, some risk factors. And what they showed was risk factor management or modification were independent predictors of arrhythmia-free survival. So, you know, like you're curious, you know, about, you know, what that means, you know, what kind of things, you know, they did for risk factor management. So this is what they did. So, you know, I mean, you know, this is, you know, they did, you know, like basically, you know, lots of risk factor management interventions, including blood pressure management, weight management, and hypercholesterolemia, or lipid management, and glycemic control. And if somebody has sleep apnea, they were started on CPAP, and also smoking cessation and alcohol cessation. So this is what they did, and this is what we tend to do in primary care settings. So this basically showed, this is like Kaplan-Meier curve from the ablation, or with ablation, single ablation, or with multiple ablations. Again, those who are in risk factor management group is shown to have a better freedom from AF compared to control group. So this is a very, very important question study that in AF risk factor management. So again, like SOS, and always optimize all modifiable risk factors. And we have so many class one recommendations. I mean, this is like a very, very important, I mean, it's very, very challenging to do in like a daily practice, but it is shown to be very, very effective. And this is something that like a guideline recommends that includes basically like a risk factor management, targeting obesity, physical inactivity, and alcohol consumption, smoking, diabetes, and hypertension. And also they recommend moderate to vigorous exercise or physical activity. And the physical activity has been shown to be associated with reduced risk of atrial fibrillation. And they recommend class one recommendation. And also, of course, smoking cessation is something that have been known and there is no change, but that's still like a class one recommendation. So the question is, I'm pretty sure that you love coffee and that you may enjoy wine or beer on the weekends. And I'm like you, I drink coffee every morning to wake up in the morning. On the weekends, I love, personally, I like wine. But how about this coffee or alcohol? Do they say anything about these in guidelines? The answer is yes. So good news and bad news. Good news. So this is for caffeine. So basically, they said for patients with AF, recommending caffeine abstention to prevent AF episodes is of no benefit. So that means it's okay to basically to drink coffee although you have atrial fibrillation. But here, it says, if there are some people who got triggers by atrial fibrillation, like some people say, I drink coffee and I get atrial fibrillation after that, like this situation, then you're like, probably we have to say, oh, probably, why don't you cut back on caffeine? But like, and also caffeine could trigger PACs or PBCs, but has no association with atrial fibrillation. So at least good news. But the bad news is alcohol is shown to be associated with risk of atrial fibrillation. I mean, sometimes people say, like I drink wine and I got atrial fibrillation just after that or a few hours after. That appears to be very, very accurate or correct. There are at least two studies, one from Australia, looking at, basically comparing somebody with alcohol consumption or somebody without alcohol. Basically, they ask them not to drink, and they show that those who did not drink alcohol was better off regarding risk of atrial fibrillation. And also there is another study from California looking at refractory period in atrial fibrillation, alcohol level on atrial fibrillation, and unfortunately, there is some association. So if somebody wants to stay away from atrial fibrillation, so then I think cut back or minimize or eliminate alcohol consumption is very, very reasonable. So it's actually a class one recommendation. So now we are going to S part of SOS, stroke risk. And I think not so much updates in this area, but there's some important aspects. So let me start with stroke risk. So this, we use CHAS-VASC score. I know in like a registry, we use CHAS-VASC score. But either way, this has been used since 2010 ESC guidelines. And the caveat is that if you're over to CHAS-VASC score of two, that means you have 2% annual risk of stroke. So that's kind of where we are. So we say, if you know CHAS-VASC score of two or higher, then let's use blood thin medication or anticoagulation. So that's kind of like how we used to do. And this is a new update. So before that, looking at your class one recommendation, we know that CHAS-VASC two in men and three in women. So these are basically like somebody who we recommend anticoagulation, but they gave us number. That means this group is over 2% annual risk of stroke. So they kind of come up with like a absolute number to kind of define the risk of atrial fibrillation. That's something new. And also they, like class one recommendation, this is from 2019 updates, but we recommend drugs over vitamin K, antagonist or warfarin in somebody who needs to be on, like anticoagulation for non-valvular atrial fibrillation. But that's been like no change. But there are the three things, there are some changes. So this, so like a CHAS-VASC one in men and the two in women, this is somebody who kind of we said, well, you know, to be recommendation, you know, like on the prior guidelines saying, well, you know, like if you want to, you know, like be on, you know, Blastiner, that's okay. But it may be not, you know, on the prior guidelines, basically, you know, this group was open to all the options, but in this new guidelines, they recommended or upgraded the recommendation from 2B to 2A in somebody with, you know, like CHAS-VASC of one in men and the two in women. And also they gave the number, you know, again, you know, this, you know, like a, you know, group is, has like a higher than 1% of annual stroke risk, but less than 2%. So, I mean, that's a new kind of, you know, development. But again, you know, the most important thing is, you know, like they gave 2A recommendation. It's a little stronger recommendation. So I think, you know, that's kind of, you know, like something that, you know, we were, you know, like thinking given the ESC guidelines showed, you know, it's kind of similar recommendation a few years ago. But here's a two, you know, new, you know, like updates. So if, you know, you practice, you know, for a long time, you may remember, you know, like, well, you cannot take, you know, anticoagulants, maybe try, you know, aspirin. And aspirin may be, you know, like a beneficial for somebody with some risk. But in this new guideline, they said, you know, aspirin either alone or in combination with Clopidogrel as an alternative to anticoagulation is not recommended. So this is a class three recommendation. This is a very, very important. And also, I mean, sometimes we say, well, you know, you don't have any, you know, risk factors, but maybe, you know, like, you know, taking, you know, like, you know, maybe aspirin may be good for, you know, somebody without any, you know, risk factors. But, you know, the guideline, new guideline says, you know, there is no, you know, benefit in this kind of situation. So basically, you know, like this, you know, new guideline says, you know, there is no, you know, room for aspirin. So that's kind of, you know, like a very, very clear. And this is, you know, like, again, you know, like a summary of, you know, what I, you know, explained to you. You know, now we got number for, you know, like annual risk of stroke based on CHAS-VASc score. The, you know, one to 2% risk category is now a 2A recommendation. That's kind of, you know, also, you know, like aspirin is no harm, no benefit or harm. So no aspirin. And also there's another update in, you know, like a stroke prevention error. There used to be left atrial appendage closure, you know, device or occluder, used to be 2B recommendation on the prior recommendation. Now it's upgraded to 2A recommendation. So there is some, you know, change to, you know, like I remember. So this is the last part of my talk, but, you know, like SOS and the symptoms. And I know that, you know, Dr. Yusuf explained to you about AFU ablation. So I think there is a, you know, like a little bit of overlap, but I think this is a very big, you know, field. So I think, let me explain to you. By the way, so this symptom management has both rhythm management or rhythm control and rate control. So rate control is very, very important. I mean, there are some people who have, you know, like a, you know, basically symptoms just because, you know, they are in tachycardia. I mean, I can imagine that if, you know, your heart is racing, like around 40 beats per minute, you know, that tachycardia itself, you know, could cause basically, you know, symptoms, you know, like you may feel dizzy and you may pass out and, you know, these kinds of things. So, I mean, you know, very, very important, you know, to control, you know, heart rate. And, you know, to be honest, you know, this has not changed. So, I mean, I will just be brief, you know, like there are many medications, you know, that we use based on ejection fraction. If, you know, patients have, you know, depressed ejection fraction, you know, we only have, you know, beta blocker. Otherwise, you know, you have, you know, like a calcium channel blocker or beta blocker for somebody with preserved ejection fraction. The digoxin is a good, you know, like a option, you know, two-way recommendation for rate control. But I think caveat here is, you know, rhythm control. So, you know, there are some, you know, like, you know, patient characteristics, you know, we kind of favor or patients favor, you know, rhythm control. That, for example, like if patients prefer, you know, rhythm control, basically, you know, we say, you know, that's a great idea. And if, you know, they are younger and earlier stage of atrial fibrillation, and, you know, like very, very symptomatic with atrial fibrillation, you know, basically, you know, we kind of, you know, like I recommend, you know, towards, you know, like rhythm control. And as you know, you know, like atrial fibrillation is caused, you know, from, you know, changing, like atrium, you know, like, you know, electrical remodeling plays an important role. Then, you know, like if, you know, they have smaller left atrium, we assume that their AFM may be a little earlier stage, or, you know, if, you know, they have, you know, more LV dysfunction, that means, you know, like atrial fibrillation may contributing to, you know, like the weakening of the cardiac function. So these are kind of, you know, things that we kind of, you know, like, you know, kind of weigh in when we think about, you know, rhythm control. But either way, so let me come back about atrial fibrillation. So I told you, you know, like I showed the EKG with atrial fibrillation, and it's very, very simple. And, you know, like, it's very, very, you know, like smart, you know, genius, and like I showed, you know, that basically atrial fibrillation came from, you know, pulmonary veins. You know, that's, you know, upstream from, you know, left atrium, and I don't know how, you know, like, you know, they come up with this idea, and, you know, it's very, very wonderful. And they show that, you know, atrial fibrillation is coming from, you know, these pulmonary veins, and this is, you know, like a landmark trial or study almost like 20 or 25 years ago, but this still concept holds. So basically what we do in somebody with atrial fibrillation is, you know, we do, you know, isolate pulmonary veins by either RF ablation or cryo ablation or with laser or, you know, like a PFA or, you know, something like that. This is a picture from Yellowstone a few years ago. So let me talk a little bit about some studies on rhythm control. So this is a landmark study. It's four years ago, and it used to be a new study, but it's, you know, like four years old. Very, very important study called East AFNET4 trial. What they did was basically they looked at patients with older people with some risk factors, and what they did was they did either, you know, like a rhythm control strategy or, you know, aggressive rhythm control management, or they did, you know, like a usual care, and they compared for the outcome of composite of death from CV causes, stroke, or hospitalization with heart failure or ACS, and they followed five years. And what they showed was, you know, basically, you know, like those who are in rhythm control group showed what's found to be, to have less, these, you know, composite, you know, outcomes. They concluded that early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care among patients with early atrial fibrillation and the CV conditions. And it's a very, very important study. And, you know, what, I think, you know, like we really need to look into, you know, what, you know, they did. So what they did was they enrolled a little, you know, like a patient with more like risk factors, but they got an early atrial fibrillation diagnosis. You know, the diagnosis of atrial fibrillation was very, very, you know, short. I mean, short is like less than one year. I mean, not, you know, too short, but still short. And they enrolled somebody with 75 years old with history with TIA or stroke, or two of the following, you know, these, you know, risk factors. And what they did was, I mean, probably this is, you can see this, but, you know, like what they did was they did, you know, rhythm control management in rhythm control group, meaning that most of them use anti-arythmic drugs. And, you know, like at two years, you know, I'd say, you know, like a very, very small, but most of them are on these anti-arythmic drugs. And they compare to those who, you know, or a regular, you know, like a group, and they showed that basically, you know, like a, if you know, you know, somebody's on rhythm control group, they have a, you know, less, you know, like these primary end points. And this is a kind of a survival curve showing that, you know, those who in early rhythm control was associated with a better outcome compared to usual care. I mean, if you treat as usual, this is, you know, what you will expect, but they were able to show the benefit of, you know, this, you know, strategy. And that was a kind of, you know, very, very impressive. So the other question is, so we talked about atrial fibrillation, and, you know, prior guidelines, we, they recommend, you know, like atrial fibrillation in somebody who had, you know, like a, whose, you know, anti-arythmic drugs were ineffective, meaning that they, you know, ask, you know, like a people to try, you know, anti-arythmic drugs before. The question is, you know, rather than using anti-arythmic drugs, how about using, you know, like a, you know, atrial fibrillation ablation as a first-line therapy? And, you know, like to answer this question, there are two important studies that I want to, you know, like explain to you today. The first is called STOP-AF study. This is from US. They enrolled 203 patients with paroxysmal atrial fibrillation, and they did, you know, like a, either cryoablation or AAD or anti-arythmic drugs, and their outcome was a treatment success. So that's our first study, and very, very similar study from Canada. It's called ALI-AF study. They enrolled 303 patients with symptomatic paroxysmal untreated atrial fibrillation, and the modalities are same, cryoablation versus AAD, and their outcome is, you know, their outcome was basically first documented recurrence of any atrial tachyarrhythmia. So rather than STOP-AF, it was saying, you know, like, you know, treatment success, and, you know, like ALI-AF is, you know, like flip side of the coin, basically, you know, like, you know, looking at recurrence. So what they showed was, you know, in STOP-AF study, basically, treatment success was much higher, like 74% in ablation group versus 45% drug therapy group. The same thing for early AF study, they look at a recurrence rate rather than success rate. And the recurrence rate was 42% in ablation group compared with antireumatic drug group, like 67%. If you look at Kaplan-Meier curve, this looks so similar. So basically, from these studies, now we got a class one recommendation for atrial fibrillation ablation. So this is a new guideline recommendation. This is for somebody without atrial fibrillation. Again, shared decision making is very, very important. And then, as I mentioned, somebody with atrial fibrillation who have failed antireumatic drugs, catheter ablation has been recommended. But now we got the new class one recommendation as a first line therapy for selected patients. The quotation is, younger with few comorbidities. That's basically a class one recommendation. Other thing that I want you to keep in mind is other recommendation. We use antireumatic drugs every day. But this only has up to 2A recommendation. This is a very, very eye-opening for me, because that's something that I have been using. And I thought a recommendation must be higher, because I have been using so often. But actually, it's a 2A recommendation compared to class one recommendation for catheter ablation. This is, again, for medical therapy, for atrial fibrillation. If you do not have structural heart disease, you are open to all these options. Remember that amiodarone is not the first line therapy. I want you to try other medications first, because amiodarone has lots of side effects. That's what this figure says. So this is the last stop. So we talked about atrial fibrillation, catheter ablation, rhythm management. How about the AFib patients with heart failure? This study is getting even older. This study was published in 2018. I cannot believe this is that old. But this is like a breaking trial. So what they did was that they enrolled patients with symptomatic paroxysmal atrial fibrillation or persistent atrial fibrillation with heart failure with reduced ejection fraction. They have defibrillator in place, and they randomized patients into ablation or medical therapy group, and they followed up to 37 months. And they looked at very, very hard endpoint, death from any cause or hospitalization or worsening heart failure. They showed that this primary endpoint occurred significantly fewer patients in the ablation group than in the medical therapy group. And the hazard ratio was 0.62. So that means they decreased risk of these outcomes by 38%. It's a huge reduction. But anyway, so that was just before the update guideline from 2019. And at that time, they gave 2B recommendation for ablating or catheter ablation in somebody with atrial fibrillation and heart failure with reduced ejection fraction based on like CASEL-AF and the AATAC trial. Then, you know, like ESC guideline recommended a little higher recommendation. This guideline was a few years ago. This is something new. So we know that, you know, like somebody who suspected, you know, like tachycardia-mediated cardiomyopathy, we know that, you know, like a rhythm control strategy is very, very, you know, beneficial because, you know, tachycardia is usually, you know, like causing weakening of the, you know, like cardiomyopathy or heart. But this is something new. So in this guideline, inappropriate patients with AF and HF patients on GDMT, reasonable expectation of procedural benefit, catheter ablation is beneficial to improve symptoms, quality of life, ventricular function, and cardiovascular outcomes. This is a class one recommendation in the most recent guideline. Also, you know, they, okay, you know, addressed another condition called HF-PEF. They documented about, you know, benefit or, you know, like, you know, like indication for somebody with HF-PEF situation. And they gave 2A recommendation in somebody with atrial fibrillation and HF-PEF patients. So this is kind of, you know, like a new change. And again, this is a kind of figure that basically shows how to manage, you know, somebody with atrial fibrillation and heart failure. Weight control is very important. And also rhythm control, usually, you know, like somebody may need to be cardioverted to see, you know, how they are doing. But also, you know, they mentioned, you know, those patients who may or who are likely to benefit from catheter ablation, you know, like in this, you know, like category. They mentioned, you know, like a, like a tachycardia-mediated cardiomyopathy, an earlier stage of heart failure, no scar on cardiac MR, or no or mild atrial fibrosis, or, you know, earlier stage of atrial fibrillation on younger patients. These are patients who may get benefit from having catheter ablation, and they recommend, you know, plus one recommendation. So, I think I covered, you know, like very, very quickly, and I hope, you know, you get some of the, you know, recommendation, but I think I want you to think about three, like, take-home messages, only three. So one is, you know, like the new, there is a new AF classification. Remember, you know, the, like, stage, you know, like one through four, or, you know, like a kind of circle, you know, one, two, three, four. That's a kind of, you know, new kind of classification. And AF is like a, more like a disease continuum. It's a kind of, like a new, you know, like a whole take-home messages. And, you know, second part is, you know, there is a paradigm shift toward our rhythm control. You know, catheter ablation is, so it's a class, you know, number three is a new AF ablation receives class one indication for first-line therapy in selected patients, and also class one indication for appropriate patients with HEF-REF patients. So three, you know, like a kind of, you know, like a, you know, take-home messages, classification, algorithm control, and, you know, like a one, class one recommendation, indication for first-line therapy on the HEF-REF patients. I think that's the end of this, my presentation. And thank you for the, you know, like listening to my lecture, and this is my two pictures, and this is a, left side is a picture from New York Central Park, and the right side is Lake Champlain in Vermont. Thank you very much for your attention. Thank you. All right, a few questions from the audience have already come in, and it looks like we'll have time to take a few others, if you wanna keep them coming. We've got two around initial presentation of AFib. What value do you place in consumer wearable alerts and monitoring in the current state of iteration and technology? I think, you know, I enjoy, you know, like having a wearable. I mean, you know, like very, very often, you know, like, you know, sometimes, you know, like a wearable says possible atrial fibrillation, but I think, you know, it needs to be reviewed with, you know, like, you know, like, you know, like basically providers. I mean, you know, sometimes, you know, like, you know, just, you know, artifacts. I mean, you know, it's a, I mean, it's a good, you know, like, it's a very, very nice tool for somebody who may have atrial fibrillation. So from that perspective, for stage two, you know, like a patient who need, you know, like a surveillance, like a wearable is very, very good, but like sometimes, you know, like a wearable could, you know, cause, you know, like anxiety, and I think I've seen, you know, somebody who's so anxious, and I'm, you know, I'm reassuring, you know, like them, you know, this looks great. I mean, you know, there's nothing to worry about, but, you know, sometimes that causes, you know, anxiety, and that's, you know, I mean, you know, like a double-edged sword, but I think overall, I think, you know, wearable is, you know, very, very, you know, like a beneficial in, like, heart rhythm patients, and I'm hoping that, you know, wearable will be more accurate. I think, you know, it's getting, you know, more and more accurate. You know, like I do, I do use, you know, Apple Watch, and, you know, like a first generation, like this is, you know, my observation, but, you know, first of, like a generation, Apple Watch was, you know, not so great. You know, like I was in, I like running, and, you know, like, you know, my Apple Watch said, you know, you're in tachycardia, and, you know, like, you know, it says, you know, my heart rate is 190, and, you know, I'm an electrophysiologist, I check my pulse, and, you know, no, there is no way, you know, it was, you know, 190, but, you know, from that time, it's getting more and more sophisticated, but I think things will be getting more accurate, I think. Great. The next is, can you share any pearls for the diagnosis or treatment of female patients? This person is seeing a lot of late presentation of women with AFib. I see, I see. I think, you know, there is some, you know, like a, you know, I would say, you know, like a gender difference, and, you know, sometimes, you know, people may, you know, like, present a little later time, or, you know, like, symptoms may be a little different, and I think, you know, like, that's a good point, you know, to keep in mind, and also, I think, you know, like a Chaz Vax, if you look at Chaz Vax score, you know, like a, you know, used to be, you know, like a female sex, you know, used to be, you know, like a counted as one, but now it's, you know, like a, basically, like a Chaz Vax, you know, recommendations, you know, like two in men and three in women. So that means, you know, basically we stopped, you know, calculating, you know, like a female, you know, like a, you know, sex for, you know, like a stroke, you know, risk, you know, as a risk factor, and then, you know, like the guideline says it's a risk modifier. So I think that's a, you know, another good point, but I think, you know, like a presentation could, you know, differ, and also, you know, like I say, there is, you know, some change in like a hormones, I think, and I think that might, you know, play some role, but I think really depends on, I would say, you know, like a case-by-case. Great. The next one is with the new class guideline for ablation, do you foresee any regulatory mandates for ablation quality reporting similar to other procedure reporting like LAAO? And Christina and I can speak to that if. I think, yeah, I mean, you know, like it's most likely we'll need, you know, to have, you know, some kind of, you know, like a, you know, like a kind of, you know, like a regulation or, you know, like a some, you know, input regarding what, you know, like we do for AFib ablation. And as you might have heard from Dr. Yusuf's lecture, you know, like there are so many ways of, you know, doing catheter ablation, and we know that we do, you know, catheter ablation, but sometimes, you know, people, you know, like do very, very differently. But the only thing that I can tell is, I think, you know, like they isolate pulmonary veins, and that's a kind of cornerstone of, you know, like what we do. But I think, you know, like still, you know, like posturable isolation and so on, you know, we have no, you know, good, you know, result for, you know, this kind of, you know, situation. So I say, you know, still like it's kind of a moving target, but I think, you know, like a more standardization, or, you know, like to follow these, you know, like kind of, you know, like a dataset, you know, by, you know, registry will be, you know, very, very helpful. And I would add to that, we've seen procedure volumes in the registry go up quite a bit in the last year, even with a stable number of sites participating. We don't think CMS would mandate AFib ablation registry participation at this stage in time, but we do see a great opportunity for EPE programs to voluntarily participate and really get a handle on some of the new technologies and the longer term patient outcomes. Next question, while pulse field ablation is likely a safer form of ablation, do you think it will have improved long-term outcomes from compared to the other forms of cryo, or the forms of ablation? That's a really great, great question. And I hope that will improve, you know, like a kind of, you know, outcome, but I think, you know, the benefit of, you know, pulse field ablation is, you know, it's safer. And I mean, like when we ablate, you know, atrial fibrillation, we really worry about, you know, like basically, you know, like causing, you know, like, you know, atrial esophageal fistula. And then, you know, that's, you know, like a very, very devastating. And then, you know, you know, at least, you know, like we can get rid of, or decreasing that kind of, you know, like a possibility. I mean, safety is very, very important. And I would say, it's a great question, but to be honest, I'm not sure. I think, you know, like we are still working on finding out, you know, how to improve, you know, like a, you know, procedural outcome, like improving, you know, like outcome, you know, due to, you know, catheter ablation. But also I, in my opinion, I think, you know, like a, you know, like a, you know, SOS, you know, like, you know, like three pillars of, you know, like, you know, like AF management, like this, you know, like, you know, like risk factor management is very, very important. And I think that will be very important. So I think, you know, like when, you know, I see patients with atrial fibrillation, I do, you know, ablation, and I'm telling, you know, like patients that that's all I can do. You know, it's up to you, you know, after, you know, like the ablation, how, you know, to improve, you know, your, you know, outcome, meaning that if, you know, they are very, very careful about your, you know, lifestyle, let's say, you know, they started to exercise, or, you know, they are careful about, you know, like, you know, like a diet, or they have lost, you know, like a big, you know, like a weight, that, you know, makes a huge difference. And usually, you know, these patients are that, you know, like that stay, you know, staying, you know, like in sinus rhythm. So I think, you know, again, you know, shared decision-making is very, very important. And I think I'm really hoping that the post-field ablation is, will, you know, like make a huge difference. But I think, you know, like there's so many rooms that we can improve in like, you know, like a care, you know, from, you know, risk factor management, and also, you know, make procedures, you know, safer. And also, you know, like ablation, you know, like a registry will play an important role as well. All right. Do you think there are unintended consequences of diagnosing a patient with stage one AFib if it's treated like a label that carries with the patient? So could it lead to more aggressive treatment, such as starting anticoagulation, when the patient never has AFib, but only the risk factors described in stage one AFib? I think, you know, that kind of, you know, like a possibility of over-treating, you know, somebody with atrial fibrillation, you know, that, you know, there is a concern raised, you know, from, you know, like wearables. I mean, you know, that if, you know, like, you know, you misdiagnose, you know, somebody with atrial fibrillation, basically, you know, like, you know, that means you may, you know, expose patients to, you know, unnecessary, you know, like a stroke, like, you know, anticoagulant and so on. But I'd say, yeah. So I think making a diagnosis, you know, accurate diagnosis will be very, very important. And I think from that perspective, I believe, you know, like you really need to, you know, focus on, you know, these, you know, like, you know, three, you know, like, you know, pillars, you know, like, again, SOS. And I think, you know, like, again, you know, like, you know, making an accurate diagnosis will be very, very important. Okay, maybe one last question. At which stage would you highly encourage primary care or cardiologists to add or consult with an EP specialist? I think, I think, you know, like, we would like to work, you know, together. I mean, you know, like, if, you know, there is, you know, some concern for atrial fibrillation, you know, like, I want, you know, like primary care doctor to, you know, refer patients to, you know, to us or to cardiology or electrophysiology. I say it really depends on, you know, where you practice. But, you know, there is some, you know, studies showing that, you know, early referral to EP, you know, improves, you know, like some, you know, like a quality of care or something like that. I think that was presented or, you know, like published in Heart Rhythm. But, you know, there are some, you know, like reports regarding, you know, like early referral. But I think as long as, you know, like, I think the most important thing is, you know, to work together. I think as you see, you know, like, you know, I showed, you know, importance of risk factor management and that's mainly done by, you know, primary care doctor. So it's more like, you know, kind of team approach, you know, like, you know, we work, you know. After I didn't show, you know, slide, but not only for, you know, like, you know, primary care doctor, but actually, you know, like it's, you know, like a real team approach, including, you know, dietician and, you know, like, you know, like, you know, PT and also, you know, like these, you know, like other, you know, like people. And so I think, you know, getting, you know, like a good team and, you know, taking care of patients together will be, I think the way to go. Okay. Thank you, Dr. Suzuki. And thank you all for being here. Thank you very much. Thank you.

atrial fibrillation

AFib management

catheter ablation

AFib guidelines

risk factor management

wearables

patient-centered care

lifestyle changes

pulse field ablation