Chapters Transcript Video Advances in AFIB Ablation Yeah, great Thanks to the conference organizers uh dr kiel for inviting me to speak this morning. I'm going to give an update on atrial fibrillation ablation of no disclosures and so and and to start. We know that sinus rhythm is better than atrial fibrillation. Even if it's rate controlled atrial fibrillation. We also know that medical rhythm control is only modestly effective with no clear benefit over rate control strategy and trials. Ablation is more effective than medical rhythm control. And we'll review some of the data for that. Also review diverse peri procedural management strategies that have improved safety with ablation. And we'll review what we feel is some of the more exciting advancements in ablation technology. So atrial fibrillation is not benign. It's not immediately life threatening for the vast majority. But in the long run it leads to complications. Um There's decreased quality of life with symptoms their stroke and from metabolic complications. You can have issues with both fast and slow heart rates that sometimes require pacing support. It could precipitate heart failure and lead to cardiomyopathy. These uh and there is decreased longevity with atrial fibrillation. In terms of, you know, timing. There's been some recent work that demonstrated superiority of an early rhythm control strategy. Uh multiple uh countries participated in this recent published uh report in which uh randomization to rhythm versus rate control. Early demonstrated combined endpoint benefit when you look at cardiovascular death stroke. Heart failure. Um for early rhythm control. When you look at, you know, what's the best way for rhythm control compilation uh studies have demonstrated superiority to catheter ablation. Um This meta analysis of 11 randomized controlled trials of almost 1500 patients demonstrated a pretty clear benefit to catheter ablation. When you look at subgroup analysis, this is where we start to see um greater benefit and particularly in the heart failure population, where we start to see mortality benefit. And this trial looked at ablation versus amiodarone in a heart failure population with marked improvements and and heart failure um and the harder endpoint of mortality. And if you look at two year all cause mortality, They found a 10% absolute risk reduction or a number needed to treat of 10 for benefit to catheter ablation. Uh This is a bit of a later trial but basically demonstrating similar and confirmation to the prior result. This looked at ablation versus drugs, both for rate and rhythm control. Um they didn't want it to just be an amiodarone versus ablation trial. Again demonstrating superiority to ablation for both heart failure uh and mortality with low numbers uh needed to treat. Looking at ablation for first line therapy. And this is where we've been moving to, I think all of us that do a lot of a fib ablation, you know, believe that we've seen in our own populations and whatnot. But looking again at a meta analysis of over 1200 patients, six trials for paroxysmal atrial fibrillation, you see in 30% absolute risk reduction for recurrent atrial arrhythmias, you see a 13% absolute risk reduction for hospitalizations and a trend actually in favor of ablation for less adverse events. Um When we look at first line ablation for persistent atrial fibrillation, there's limited data thus far, we do have a ablation trials after anti arrhythmic drug therapy which is demonstrated improved effect effectiveness. We also know that the and have results that the earlier we target ablation strategies, the better the patient does. So when you look at early versus later in the course of persistent atrial fibrillation, patients do better. And we know that patients do don't do well with longstanding persistent atrial fibrillation as it's quite difficult to achieve enduring sinus rhythm in terms of our Sentara experience, we've got a mixed uh data on it. I put this up because we've been involved in in in some of the more recent, you know, trials looking at um how we do with uh newer strategies And and we were one of the leading N rollers in the short trial, which was just published um that looked at the Contact Force Technology for management of paroxysmal atrial fibrillation. And the results are pretty similar with other trials and sort of demonstrating improvements with a strict um uh you know, uh strategy of monitoring, showing almost 82% 1 year um enduring rhythm control in terms of other techniques that have been used to both decrease the safety and also enhance the effectiveness of ablation. I'll go through some of them probably one of the most important ones and certainly for stroke risk reduction is the movement a few years back to uninterrupted Orlando coagulation um that had been started in other areas with atrial flutter and some other things. But Uh this is really markedly reduce stroke risk to where it's almost not seen any longer. Uh compared trial back in 2014 compared Coumadin found a reduction from 3.7% to 0.25% with uninterrupted Koonin. We participated in the trial which is an international trial again, one of the leading n rollers looking at a pixel ban versus Warfarin uh and a non inferiority trial showing a similar uh effective stroke risk reduction a 10.3% for a pixel ban. Similar trials have also been done looking at the docks urban and River rocks Urban. There's also been a trial data demonstrating lower bleeding with direct Orlando wagons with the re circuit trial demonstrating a marked reduction and major bleeding interestingly with the bigger trend as compared to warfarin use of ultrasound guidance, which has really become standard of care and was a change for us. And I think largely driven by uninterrupted Orlando coagulation as there are greater concerns particularly with jack use uh and trying to keep them out of the vascular O. R. S. But this has led to major reductions Excuse me in major and minor vascular bleeding Use of high frequency, low tidal volume mechanical ventilation um And also competent rapid atrial pacing has been really helpful for improving contact force uh with significant reductions and procedural time. First past pony in isolation. And uh and there's also data demonstrating that getting first past pulmonary vein isolation has improved efficacy using vascular closure. Um At at the end of the case has been uh demonstrated to decrease um throughput or improved throughput I should say decrease time after a vascular closure uh improve efficiency in terms of getting patients home and also decreased vascular complications. Use of no very low flora Skopje use with reductions and radiation exposure uh Being able to go lead free with the benefits to that. And trials have shown similar safety and and time. I'm just gonna show a couple of slides here demonstrating uh no Flora Skopje catheter positioning. This is the C. S. Lead being put in, this is trans septal puncture and on the left is our non flores, coptic mapping system with intra cardiac echo. And there we get transept the puncture. This is creation of the left atrial anatomy first with the left side of veins, then the right side of veins. And we're creating our left actual anatomy and that's enabled us uh to not be reliant on pre procedural um uh imaging which has been quite helpful and this is a demonstration of the endpoint or the foundation of what we're trying to achieve with uh a fibrillation that's point of in isolation if you look on the left part of the slide um you can see the sleeves that, that purple going into the veins of electrically active tissue that leads the triggers and the annual region of that initiating substrate that drives atrial fibrillation on the right side. We can see that we've isolated it. This slide is sort of a great demonstration and proof of concept if you will. So if you look at it, there's a catheter in one of the veins and that catheter demonstrates atrial fibrillation. And then if you look on the right side of the screen, the left atrium is actually in sinus rhythm. Um and so this is just I think just a wonderful demonstration of, of the importance of isolation of the veins. This is a demonstration of why we also though have to look at extra pulmonary vein drivers, particularly in persistent atrial fibrillation. And this is a case that are somewhat recently had, where we had the veins isolated uh in a persistent atrial fibrillation, patients with left atrial myopathy and you can see all the red kind of on the anterior scar and in achievement of the anterior scar isolation, uh we achieve sinus rhythm and termination of the atrial fibrillation. So, advancements uh and this is the area that we're most excited about is pulse field ablation, which is a non thermal type of ablation and with that we feel that we can enhance the safety profile, particularly with the ability to prevent esophageal injury, frantic nerve injury uh and eliminate pulmonary vein stenosis concerns. This is the uh slide showing the the tool that we use for the sphere af trial which is a catheter that can toggle back and forth between pulse field and radio frequency ablation. And this is showing a demonstration uh between each technology and achievement of pulmonary vein isolation. When you look at the pulse field ablation trials to date, um we see a very good one year survival uh free survival of 87% and with no um esophageal injury, pulmonary vein stenosis or frantic nerve paralysis. So in summary atrial fibrillation is not a benign rhythm. Rhythm Control is our preferred management strategy, particularly in young symptoms. Symptomatic patients or patients with heart failure, cardiomyopathy. These sinus rhythm is best achieved with ablation, those significant improvements. And the tools set. More work is needed both in understanding mechanisms, targets and tools and with that. I'll just say thanks to all thanks to the team. This is a picture after our first day with the sphere af trial and just want to acknowledge everyone's efforts uh to include our uh technical support staff, uh nurses, administrators and a great team. So thank you Published Created by Related Presenters Philip Gentlesk, M.D., F.H.R.S., F.A.C.C. Sentara Cardiology Specialists View full profile
BROADCASTMED