»» Okay. Thank you. Welcome. Good afternoon. My name is Patti Largen. I'm the Registry Manager for the AFib Ablation Registry. And I wanted to give you a little housekeeping tip in regards to the Q&A. It will be held at the end of the presentation, but we recommend that as you're in person, use your mobile app to submit questions for the speaker. To submit a question, please find the presentation under full schedule and then look on the tile for the presentation on the app home page. Select the correct presentation title and at the bottom of the page you will see a tab that says Q&A. Open that up and submit your question. Please feel free to submit as many questions as you have. She's also very interested in medical education and is heavily involved in the residency and fellowship program in her home institution. She is a passionate advocate of providing equitable healthcare and serves as a Board Member of the Cardiology Education Foundation, an organization dedicated to promoting cardiovascular education, research and patient care in the underserved communities, especially in Sub-Saharan Africa. In her free time, she cherishes lazy days, enjoying the Houston heat with her husband and two children. Welcome Dr. A. Kerbo. Well, thank you everyone. Thank you to the ACC Quality Summit for having me come on board to discuss this very timely discussion or something that I'm always very excited by, atrial fibrillation. Let's see, how do I advance these? Ah, okay, there we go. So the topic that we're going to be discussing today is about atrial fibrillation, so many ablation strategies, how to choose. And you might be asking yourself, well, are there many ways of ablating atrial fibrillation? What else should we be thinking about? 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And the reason why it's become a little bit more popular is because it's so easy to miss. And the reason why it's become a little bit more popular is because it's so easy to miss. And the reason why it's become a little bit more popular is because it's so easy to miss. So if you look at those white lines, that represents electrical activity. So if you look at those white lines, that represents electrical activity. So if you look at those white lines, that represents electrical activity. So if you look at those white lines, that represents electrical activity. And you can kind of see that it's not synchronized. And you can kind of see that it's not synchronized. It seems to be coming from everywhere and going everywhere. It seems to be coming from everywhere and going everywhere. It seems to be coming from everywhere and going everywhere. So much so that your atrium is not able to do anything about it. So much so that your atrium is not able to do anything about it. So much so that your atrium is not able to do anything about it. So much so that your atrium is not able to do anything about it. So even though you have a lot of electrical activity, you don't have that much mechanical activity. What does that mean? The electricity is just going haywire, and then the atrium is just not doing anything. So it's not squeezing the way that it should. Why is that important? Well, the atrium and the atrial contraction contributes about 10 to 15% of the cardiac output. So all of a sudden, when you have atrial fibrillation, that 10 to 15% goes away. So a lot of the time, you can accommodate for it, but there are some times when it becomes really important. For instance, if you have a thick heart, if you're not able to relax as much, then that becomes a little bit of an issue. And so we try to figure out, well, what causes atrial fibrillation? We've seen associations with a lot of different conditions, heart failure, hypertension, aging, or like I like to say, getting a little bit more mature and wiser with time, genetics. There's some young people who end up having atrial fibrillation. If you have diabetes, if you're obese, if you have obstructive sleep apnea, that could lead to atrial fibrillation. And all of this comes together to form AFib. When do we start to worry? Well, the main things that we worry about are the risk for stroke and also the risk for heart failure. So for stroke, we give anticoagulation, heart failure, this is where it becomes a little bit important for us to take care of it. So they've been talking about atrial fibrillation for such a long time. This is Dr. James McKenzie, who in 1905 wrote this paper where he was explaining what happens with different heart disease states. And he was talking about atrial fibrillation, but in the context of heart failure. 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And they end up getting really sick. And they end up getting really sick. And they end up getting really sick. So the older you get, sometimes people have high blood pressure. And they might be on beta blockers. So they might have atrial fibrillation. But the atrial fibrillation rate is low. And they won't have symptoms. So those are the things that we bear in mind when we see patients who have their first diagnosis of atrial fibrillation. Now if they have multiple diagnoses of AFib, then we know that, OK, this is probably paroxysmal. Each episode has to last less than seven days. If it lasts more than seven days, and actually more than 14 days, then we worry about it being persistent. If it's longstanding persistent, that means that it's lasted for longer than a year. And then permanent atrial fibrillation, sometimes I see this in the chart, and the patient is not aware that they're in permanent AFib. So bear in mind that permanent atrial fibrillation is actually a discussion that is had between the physician and the patient, where we say, you know what, we're not going to do anything about this atrial fibrillation. We're dedicating ourselves to a rate-controlled response. And we're not going to try to cardiovert. We're not trying to do an ablation. You're just going to be in atrial fibrillation for the rest of your life. Now that there are so many ways of treating atrial fibrillation, maybe this is not seen as much. But sometimes it can happen, particularly in patients who have valvular disease. So if they have mitral stenosis or severe mitral regurgitation, then this might be something that we'll actually say to the patient. So the second question is, okay, you've decided to treat atrial fibrillation. What should you do? Should you go for rate control? Or should you go for rhythm control? Rate control means you're just trying to, instead of the heart rate going fast, greater than 100 beats a minute at rest, you want it to be about 80 beats a minute at rest. It can get up to 120 beats a minute with activity. This we do with beta blockers, calcium channel blockers, digoxin. And in some rare cases, we will do an AV node ablation in these patients. And an AV node ablation is basically where we burn the bottom of the AV node so that there's no conduction between the top and the bottom chambers. Most of the time, we don't go for that immediately because that means that the patient is pacemaker dependent and so we don't want to do that, unless it's absolutely necessary, of course. Now rhythm control is where we try to put the patient in sinus rhythm. So how do we do that? Well, we can give them medication. And for a long time, that was the only option that we had. So we would give amiodarone, Sotolol, flecainide, dofetilide, ibutylide. All these medications can put the patient back into a normal rhythm. But the success rate is really low. So for amiodarone, the success rate is about 60%. And everything else falls below that. For Sotolol, it's about 50, 40 to 50%. And for flecainide, it's actually about 30%. So with those numbers, it's not really the way that we would like to go and that's the reason why ablation becomes a little bit more of the process that we go through these days. So rate control versus rhythm control, I'm sure a lot of you have heard about this quandary. At the time that I was in medical school, actually, this discussion came about this was published in the New England Journal of Medicine, the great affirmed trial that basically talked about rate control and rhythm control in patients. And what they did was they took patients and decided, okay, we're going to go with a rhythm control strategy. And another set of patients, they decided to go with a rate control strategy. Now you have to remember, this was in the 1990s to the 2000s, really in the 90s, right? So we didn't have that much in regards to rhythm control. So this was really a trial where we were actually controlling or trying to give the patients medication to put them in rhythm control and comparing that to rate control medications like beta blockers. So that's something that we think about now when we look back at the affirmed trial. So what they concluded at the time is that atrial fibrillation with rhythm control strategy is no better, no worse than with rate control, right? And so for a long time, all I would hear is rate control is equal to rhythm control. So why don't we just do rate control? And it's the easier way to do things some of the time. Some patients have hypotension, and so you would want to cardiovert the patient. But when you look at the side effect profile of a lot of antiarrhythmic medications, then that becomes a less attractive option. So a lot of people would say, you know what, let's do rate control. Also remember at this time, AFib ablation was really not done. Remember the paper that was written about pulmonary veins and that being the source of AFib actually just came out in the late 90s, towards the end of when they did this study. So it actually wasn't robust. And even then, it took a long time for us to get to where we are today with pulmonary vein isolation and atrial fibrillation ablation. And so some people would talk about how you would go into the EP lab and you'd spend eight hours trying to ablate an atrial fibrillation. So there were complications, pericardial effusions, phrenic nerve injury, also pulmonary vein atresia or stenosis, which is terrible. And so when you think about all of that, it was only the sickest patients or the patients that you actually needed some rhythm control that they said, OK, let's try this experimental treatment. So I think that we were in a different time then than we are now. I think that we can all agree. What I think that we can take from the AFIRM trial, though, is that rhythm control using amiodarone is definitely not the way to go, because a lot of these patients were very sick. They had a lot of side effects from the antiarrhythmic medications. And that actually led to them being noncompliant with their AADs. Also another thing that wasn't done before this trial that came about afterwards is that anticoagulation is needed even though you have gotten rid of the atrial fibrillation. So if the patient is, you've decided you're going to do a rhythm control strategy, the patient is in sinus rhythm, you don't take off the anticoagulation. And it was soon after this that we actually had the CHADS-VASc score and the CHADS-2 trial that basically talked about what we should be looking at to determine if the patient should have a anticoagulation or not. So, you know, this AFIRM trial, I think that it should be looked at in a different way today than it was a few years ago, especially when it was published. A few years later in 2008, the first was done in 2002, in 2008 we had the PAVA-CHF investigation. And by this time we had done more atrial fibrillation ablations, more pulmonary vein isolations. And in this particular study, they showed that the primary endpoint, which was supposed to be improvement in ejection fraction, the six minute walk test, and also a measure of patient satisfaction, it was actually exceeded in the pulmonary vein isolation group versus patients who got an AV node and biventricular pacing. So what does that mean? That means at least in this study, rhythm control was much better than rate control because they did the most severe rhythm control that they could do. And they compared that to the most severe rate control that you could do because nothing can be more certain than getting rid of your AV node and putting in a pacemaker. There are other trials that came about that basically said, hey, we should do more ablations. The CASEL-AAF trial is another Sentinel one, published in 2018, it was a randomized control trial that basically dealt with patients who had heart failure. And in those patients, if they had persistent or paroxysmal atrial fibrillation, they compared catheter ablation with medical therapy, looking at patients with an increased NOIHA class, EFs that were less than 35%, and an ICD in place. So they were able to make sure and see those patients in whom an ablation was successful or not. The endpoint was looking at the composite of death and worsening heart failure. And what they found was that was actually better in the patients that got pulmonary vein isolation. A sub-analysis said that this was mitigated in patients who had an ejection fraction that was less than 20%. But still, patients who have heart failure do better with pulmonary vein isolation. Finally, there was the CABANA trial, which was this huge trial that went from November 2009 to October 2017, was actually published in 2019. They looked at patients who had medical control of their atrial fibrillation versus pulmonary vein isolation. And what they saw was that ablation demonstrated superior efficacy than drug therapy. So more patients who were in the ablation arm actually stayed in sinus rhythm than the ones that were in the drug arm. So all in all, a few more tests to show, hey, rate control on rhythm control could actually work. And ablation in particular was actually better than just doing medications. Now the EAST-AF-Net trial was an interesting one because it just looked at rate and rhythm control. So some people have described it as a FIRM 2.0. But in this case, they decided that, okay, let's compare early rhythm control to rate control and let's see what can happen, or early rhythm control to regular management. And actually, the rhythm control didn't have to be with an ablation. It could have been done with just medications. Actually a minority of patients, I think about 30% of patients actually had an ablation done. And what they found, so much so that they had to stop the trial early, was that if you actually had early rhythm control, and that was once you found atrial fibrillation, you did something about it, put them back into a normal rhythm within three months, those patients actually did much better. So what does this tell us? It tells us, well, if you see somebody with atrial fibrillation, you should treat it quickly as EAST-AF tells us, and then you should probably try to do an ablation rather than just leaving them to rate control, because that might be less successful. It's still just a class 2B indication for ablation, however, previously when ablation first came out, it used to be that you had to fail two medications before you should go for an ablation. Now it's actually up to the patient. So if you talk to a patient and you say, hey, there's this ablation that we could try, there's this procedure, if the patient says, yes, I want to try it, then that's totally fine. The patient can go on and do the ablation. So there are many different ways of ablating a patient. You could either burn the patient, or you could freeze the patient. So we have to decide which way we're going to go. Why do folks decide to use ice? Well, it's a one-stop shop, so you can put the catheter in, you isolate the veins with just one blow of the balloon, it's a shorter procedure. The reason why it's not as widely spread as they would like it to be is that evidence hasn't shown efficacy, at least in a randomized trial with persistent atrial fibrillation. With paroxysmal atrial fibrillation, it's not inferior to radiofrequency ablation. The second thing is that sometimes you're doing your ablation and you have other areas that need ablation, and you can't ablate it with the balloon. So you would have to break out an RF catheter to ablate those. So it ends up being a more expensive procedure, at least for the hospitals. So there's some places where they're not big fans of ice versus fire, where you're doing that's the more widely known way of doing atrial fibrillation ablations. What is the disadvantage of it? Well, it requires a lot of technical skill. So sometimes it becomes a little bit difficult for you to find enough practitioners that can do it well enough. And that affects, of course, your outcomes. So that's number one. The second thing is that it can be time consuming, it can be long. But other than that, it's the most reliable mode of atrial fibrillation and pulmonavian isolation that we have. And actually, that is now the gold standard for ablation in patients. That's what we usually compare new technologies to. Now, there are different other ways that we can ablate surgical ablations, which I think we have a session on tomorrow they're going to talk about. But they're going through a trial right now. And this is just an ablation where they've used the catheter, one that's sitting right there. They put it on the backside of the heart. So it's an epicardial ablation. And the advantage of doing that is that a lot of times it's a convergent procedure. So if somebody is having surgery, let's say they're having mitral valve surgery, if they're having CABG, that you can do the ablation at the same time. The disadvantage is that if there's no other surgery, you're doing a mini thoracotomy to get to the heart. So that's number one. And then also the fact that it's an epicardial ablation can be problematic. A lot of people think that because the atrium has such thin walls, then you should have a transmural scar, even if you're endocardial versus epicardial. But that's not always the case. And a lot of these patients, or at least a fair amount of these patients, come back to the hospital with complaints of flutter. So and then there's the new kid on the block, which is electroporation. And this is a new technology that basically uses high current between two poles to kill cells. It preserves the nerves and the vascular smooth muscle and esophageal smooth muscle so you don't worry about your atrial esophageal fistulas that sometimes can happen with atrial PVIs. It's usually a one-stop, one-shot ablation, so anybody could do it. But then sometimes the disadvantage is that anybody could do it. And actually, Dr. Kukulich talked about this on Twitter the other day, where he said, okay, you know what? This is something that we have to consider because if you're ablating too close, you could cause coronary spasm. So all of this is still in the zeitgeist. We're still talking about it. And we'll decide what's happening the more research continues to get done. So back to our patient that we talked about at the beginning. What did we do for her? Well, we decided to do a pulmonary vein isolation. We took her to the cath lab. What you typically want to see is that if you look at that picture, if you can turn your head, squiggle your eyes, you can work with me on this. The part that looks like there are two horns, those are the pulmonary veins on the left and on the right. And you're looking from the backside of the heart, and you have some at the bottom. What you want to see is that all of that gets isolated. So if it's pink, it has tissue, it has voltage going through it. If it's red, now we've isolated. And so the patient has their pulmonary vein isolation done. So that means that any fast rhythms that are coming from the pulmonary vein, they can't get out into the rest of the heart. They sometimes will do a pulmonary vein isolation as well as a posterior wall ablation, but those are for patients who are much sicker. In my case, I typically will take a look at the voltage in the posterior portion of the heart, that area that looks pink on the second picture. And if that area starts looking a little bit scarred, has a lot of different colors, then most of the time I'll actually ablate that part as well. Well in this patient, she actually did pretty well until 18 months later when she had this tachycardia. And believe me, if you can, this looks a little bit regular, but it's not, it's irregular. But then also you can see some P waves, especially in V1. This can be something that can come up after an ablation. The patient can have an atrial flutter that comes from the left side. That happens as a result of scar tissue that was formed. Sometimes there's an incomplete scar, and then you have this flutter that might go around the veins, might go into the roof. In this particular patient, we took her back to the lab. Again, as you can see, we're looking at the back of the heart. Those two, four things that are pointing out, that's the pulmonary veins. And you can see that there's some isolation, but not all isolation, right? So you still see some colors up in the top, so they're not as red as they were. But then also... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... And thank you. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...

atrial fibrillation

AFib ablation

rate control

rhythm control

medication

ablation procedures

pulmonary vein isolation

heart failure