Chapters Transcript Video Atrial Fibrillation Click here to view presentation deck Back to Symposium All right, good morning. Uh My name is Jeffrey Hedley. I'm one of the electrophysiologists here. I'll be discussing the modern day treatment of atrial fibrillation. Um I say modern day because I think that even we uh as electrophysiologist, think that we are in the middle of a uh major paradigm shift in the way that we treat atrial fibrillation. Um It's, and it's evolving quite quickly and, and to be quite honest, uh rather exciting. Um Let's see. I, oh, good. OK. All right. So modern day, let's go back. Uh Let's see. How did we used to do this? Um There, there is, uh there, there wasn't and still are three main pillars to the treatment of atrial fibrillation. Uh This has not changed. So, first and foremost, nothing in this life changes your life the way a stroke does. Uh So first and foremost, let's prevent stroke with uh anticoagulation and then there's rate and there's rhythm control and much of which we're going to discuss in terms of the changes from past to present have to do with the relative focus placed on the two of those uh other pillars largely uh what we would have done in years gone by is we would have said you come in with atrial fibrillation. However, it was diagnosed, uh we're gonna put you on a blood thinner for sure. But so long as we can gain control over your heart rate, the studies at that, you know, for a long time would have suggested there isn't a whole heck of a lot else that you need to do much of this was based on the affirm trial that showed no benefit in rhythm control over rate control. And so people uh understandably went on in atrial fibrillation for months or years at a time. Uh And, and that was the standard of care for a very long period of time. Um Part of this has to do with the fact that we have only but a few rhythm control medicines or antiarrhythmics. Um They're listed here. Um I would personally argue that drone is not a real medicine or MT. Um, it has all of the, you know, great qualities of being crazy expensive and also not effective at all. So I'm not sure why it's used to be perfectly honest. So if you take that off the list, then it's been a quarter century since the last medication was made from a rhythm control standpoint. So you can kind of understand these medicines are kind of beset with, you know, um side effects and drug drug interactions. We're not super eager to use them. So people again, marched on in atrial fibrillation for a long period of time. This is a point that I made last year when I gave this talk and I wanted to drill down a little bit more, which is what happens to the heart as it spends more and more time in atrial fibrillation, primarily the, the left atrium slowly but surely dilates over time. And as it stretches out, the nice normal healthy tissue that is there is slowly and gradually replaced by scar tissue. And this is a rather predictable, uh you know, process that uh is, is easily seen on echocardiogram. Here is the, the left atrium and this is a nice normal size left atrium, take my word for it. Um Here's an example that, you know, the, the left um left atrium is beginning to dilate, this is at least moderately dilated, it dilates a little further and then I'll give you a really, you know, dramatic um example of a severely dilated left atrium once the left atrium gets not just like this, but, you know, um to the regular severe amounts of dilation, um Much of what we're going to do does does not work anymore. OK. So when someone shows up in my office and then they say I'm here for my A FB ablation, oh, by the way, I've been in a FB since 1978. Um I'll just say that. All right. Um Not much I can do. Um So we tried to get to, uh A FB nowadays long before this happens, this is a quote that I put up last time. And I truly believe this, that the left atrial size is to atrial fibrillation. As the hemoglobin A one C is to diabetes. Ok? You can have a single spot, glucose be normal. But if your A one C is 10, guess what? You've got diabetes, right? And so sometimes, you know, I get a, a referral for people who have new onset A FB, but the left atrium is already quite a bit stretched out. And assuming there is no other independent reason for that. I know that there is chronicity to this. A FB that has been otherwise unappreciated. Uh before then. So I'll give you a good example. Here is me making an electro an atomic map of the left atrium. You're looking at the left atrium from the uh at least on the left, you're looking at it from the posterior, from behind. And so you see the back wall of the left atrium and then you see the two left pulmonary veins and you see the two right pulmonary veins and the color coding here. So red means electrically inert. Um maybe, maybe the tissue should never have um any electrical activity or it means there's scar tissue there. So the veins you can see they're all four of them are, are red deeper in the veins that's normal. They're not supposed to have electric, electrical activity there. But along the back wall, a nice normal healthy heart should be stone cold purple all the way across with no red whatsoever. So, this the, the scar tissue process that I'm talking about has already started in this patient. Although this is not very dramatic. Here's a whole heck of a lot more dramatic. Uh, example, the heart is more dilated now and now there's very little purple, there's no healthy tissue hardly at all left. It's all scar tissue. Um And uh and again, we, we really, really, really think we've gotten to things way too late if we're starting to see this in the EP lab. Here is a map. Um Not one that I pulled out of my records but quite literally did yesterday. Um You can see that there's bits islands of healthy tissue, but there's a lot of red scar specifically through the, you know, striping through that posterior wall. And not only does this make our efforts towards ablation more difficult or the long term control of atrial fibrillation more difficult, it can actually give rise to yet new rhythms in and of itself. So here on the left, you can actually see what is uh an atypical atrial flutter. So the electricity is like a dog chasing its tail in the top left chamber and it's spinning around the scar that you see there and that scar is not there from prior surgery or from prior ablation. That is literally just the patient having been in a FB too long and these flutters are very, very difficult to control. They're often prone to really bad RVR that does not respond to medical therapy. They need to be cardioverted. And really the only good therapy for this is yet another ablation. So we wanna get to the the heart lung before this, I say atypical flutter, I'm just putting this up here for reference, but I thought it was also very pretty. This is a heart uh uh a map that I made recently of typical atrial flutter. So when you see a patient in clinic and you get an EKG and they have that Sawtooth pattern on EKG, the one that we've always seen, this is what it is, it is that counter clockwise caver tricuspid is miss flutter. Um So, all right. So the modern day treatment of a FB, OK. I in kind of plain talk the way that and you're gonna think I'm very aggressive and, and a bit much. But this is, this is the honest way I think about a FB. Now, if I describe the way that I want to treat somebody with a FB, let's just say it's a 40 year old gentleman who walks into the emergency department with their very first episode of A FB. And it's not due to some other crazy, you know, reversible uh etiology. This is their first episode of A FB. I essentially want to throw them on a blood thinner, grab them by the shirt and run to the ablation. Um Because that, that's the most effective thing that's gonna happen. And if we get to it early enough, they may go an exceedingly long time if maybe never having recurrence of atrial fibrillation. Um If, if we're, if we jump in quickly enough. So the whole thing about the affirm trial and rates and rhythm control not being any different that began to unravel with trials like the east A F net four trial, which began to show superiority uh of rhythm control over uh rate control. Um You can see that with their composite outcome here and then the data began to mount ever since we started to say, ok, well, if it's better, then what about drugs versus ablation? And should we be just jumping in early with ablation? So two major studies were done uh you know, a couple of years ago, the early A F trial and then the stop A F trial first. Um And so both of which showed clear superiority of ablation over antiarrhythmic medications for rhythm control. And this was, this was true for this. Um The, the early A F as well as stop A F first, people had less recur um recurrence of arrhythmia, but also they had less progression from paroxysmal, you know, the come and go variety of a fibrillation to persistent atrial fibrillation when now you're stuck in a FB all the time and it takes us to get you out of it. Once you've made that progression to persistent atrial fibrillation, we're, we're sort of dealing with a different beast and it is far more difficult to uh control and the timing matters actually. So that's why I'm being kind of dramatic and saying I'm gonna rush someone off to the EP lab instantaneously. But this was a phenomenally good paper that showed, in fact, it's probably the first three years. That's your very short window to get someone to rhythm control management. And I like how they phrased it. If you, if you look there on the bottom left, there is no lower limit, the shorter, the better. And there is little after the first three months, essentially, the longer, the more irrelevant. So there is actually rush which stinks when there's long, you know, lines to get into the, the EP Clinic. But we're working on things like that, like dedicated atrial fibrillation clinics where we can get people in and seen and on a treatment path far quicker and they're not languishing in the interim. So a lot of this was kind of showing you. Ok. Well, we're gonna do better from an A FB standpoint um by and large. I tell most patients mostly to put their mind at rest that you know what, you're not gonna die from a FB, right? It's gonna cause a lot of issues. It's gonna make you feel bad, it's gonna land you on medicines and whatnot, but you're not gonna die. And so conversely, I would love to be telling you that I'm saving your life. But I'm really not. Um I'm mostly just trying to make you feel better on a day to day basis, but then the mortality benefit started to mount. And specifically, we're talking about patients who also have heart failure. So if you see a patient who has both heart failure and atrial fibrillation, now there actually is mortality benefit to ablating that patient and keeping them in normal rhythm. And this was true of their composite outcome of death and hospitalization for heart failure as well as independently for death and heart failure, hospitalization alone. And believe it or not, we were actually all quite surprised by this as electrophysiologists. We were surprised to see that this was true even of patients with end-stage heart failure. So I would have probably guessed that that would be a population that would not benefit from ablation and I would have been wrong. So mortality benefit there as well. So you'll see this reflected in the most up to date atrial fibrillation guidelines. You can see on the left, there is the older guidelines which will say focus on rate control, no worries about rhythm control. And now absolutely the so-called trial of sinus, anybody walks into our clinic in in atrial fibrillation, we are absolutely going to give them a shot to be in sinus rhythm, mostly to see how their symptoms are, but also establish, can they maintain sinus rhythm? And so should we push forward with things like uh ablation? And also not only should you be sort of considering ablation as part of the treatment path? Maybe a medicine, maybe ablation, who knows nowadays, level one move to ablation. So that's reflected in the most up to date guidelines. And this is our guidelines. If you look at the ESC, the European guidelines, they're actually even stronger than this. They're basically very much pushing towards um ablation. So I, I showed this slide last year. I said, look, you know, here we are where we've got a procedure that is in and out same day, sleep in your own bed, it's highly effective. Um And it only takes about an hour and a half to two hours in the, in the prior iterations. And oh, by the way, the risk of a major adverse event is under a single um percentage. You look at any of these dreaded complications like stroke and a e fistulas and pulmonary vein stenosis and whatnot. They're technically all possible, but they are a fraction of a single percent. So you're taking a greater than 99% chance that nothing is going to happen to you in the procedure and you would take those odds to Vegas every day of the week and clean up, right? But that's actually the old ablation. Ok. So that's what's radiofrequency ablation. That's where we go point by point around the, the pulmonary veins. And we're using thermal injury to create the purposeful scar tissue that isolates those arrhythmogenic pulmonary veins away from the rest of the heart. That's what's called RF ablation. And, and to up until recently, that's been the way this was done. And unfortunately, when you have a lot of pathologic remodeling, it requires a whole heck of a lot more ablation which increases your risks. But now there is a newer form of ablation and this is what is called pulsed field ablation or P FA. And you will see this everywhere nowadays, the way that this works is is that, you know, you can imagine the lipid bilayer of your cell membrane. And we all know that in cardiac myocyte, there's a resting membrane potential, pulse field ablation delivers electrical pulses, voltage across the the um cell membrane which induces poor formation in the cell membrane. And then basically irreversible cell death. And that leads to the scar tissue that we want, that creates the uh pulmonary vein isolation. The way this works is, you know, and, and this went through long years of uh of um investigation is you're delivering voltage and you have the ability to deliver uh voltage of a certain amplitude um voltage over a given amount of time, positive or negative trains of pulses, alternating pulses. And basically what was determined to that if you, you know, over lots of, of, of years of work, there's essentially a specific harmony that works on the myocyte themselves and not the surrounding structures. So it leaves surrounding structures unaffected and this leads to the electrical um electroporation, which is our, our um desired end point. So take what I said before and now change this to literally being under an hour in many cases. OK. Roughly an hour is a is a fair estimate for a standard atrial fibrillation ablation nowadays, with pulse field ablation and some are even faster than that. Um And if you go back to the risks because it is so tissue specific, some of the dreaded complications like fry nerve palsy or A E fistula are literally removed off the list of possible side effects. So it has gotten incrementally even safer than it was before. So in all fairness, it's worth talking about who does not benefit from atrial fibrillation. Ok. I'm not advocating that every human with a FB needs to go off to the EP lab, specifically extreme morbid obesity. Ok. This has been shown to, you know, really, really harm the long term effects and the likelihood of maintaining sinus rhythm um over time. And I'll go into that a whole heck of a lot more actually, really extreme comorbidities. Um comorbidities, specifically advanced lung disease and pulmonary hypertension, not only because they serve as an ongoing driver of atrial fibrillation, but also because they're very high risk for general anesthesia, which these procedures are done the very elderly patients. Now, we're routinely doing uh ablations in, in people in their eighties. Not so much, no engineer. Um but it's a case by case basis, but we're not advocating for um putting uh very elderly patients through the risk of ablation. Um We've already talked about advanced left atrial myopathy and then specifically severe untreated valvular disease. We will get our structural heart colleagues involved if we think there's an unaddressed, specifically, things like mitral stenosis, which leads to the sort of really blown out left atria like you saw before that needs to be addressed before we ever consider doing ablation. So let's touch on obesity because that's gonna be, you know, near and dear to our hearts. So, not only as you can see on the left as the BM I increases. So does the efficacy of the ablation go down and, and rather predictably, but more importantly, the risks of the adverse events go up with increasing weight. You can imagine vascular access is far more difficult. Um And so we're trying to protect our patients as well as not as a, as opposed to only avoiding, you know, a suboptimal result. But one really interesting thing is, and I push very, very hard on patients for this. A good friend of mine in, in Cleveland, um did this um study where he showed if you took obese patients and you had um some o obese patients go through bariatric surgery with successful weight loss, believe it or not, they actually did every bit as well as their non obese counterpoints. So the, the intervention is extremely, um, uh, fruitful. However, if you then look at the obese counterpoints that did not go through, um, uh, bariatric surgery that their outcomes are, are reasonably dismal actually. So, so if we intervene, especially in the, in the, uh, era of these novel weight loss medications and whatnot, I think we're doing our patients a gigantic favor. Um One of the last points I want to touch on and this, this dovetails well off of div S. Um, talk is work up of cryptogenic stroke. The crystal A F trial was extremely useful um in as much as what it showed was, the longer you look, the more likely you are to find atrial fibrillation. A lot of these, uh you know, again, cryptogenic idiopathic strokes, they were probably always atrial fibrillation. And now at least we've got people wearing apple watches or cardia mobile devices, but this particular trial was done with loop recorders and believe it or not, nearly one in three of all cryptogenic strokes um were due to atrial fibrillation. So long as you provided long enough cardiac monitoring and again, for a div said one minute, it's five minutes. But um, if you do five minute long procedure with a loop recorder, you, you will almost certainly find um, a um this is the this loop recorder as he already showed. All right. So in summary, rhythm control is now known to be superior to rate control. The time to rhythm control matters greatly. Ablation is superior to antiarrhythmics. With respect to rhythm control, pulsed field ablation is now available and is fast and safe. There is mortality benefit for ablation specifically in heart failure patients and even including inst stage, heart failure and with cryptogenic stroke, the longer you look, the more a FB you're going to find. Thank you. Published Created by Related Presenters Jeffery Hedley, M.D. Sentara Cardiology Specialists View full profile
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