My name is Laurent Max from the Montreal Heart Institute in Montreal, Canada, and I'm co-chairing this session with Maria Terry Cabras from Sunnybrook, Toronto, Canada as well. So we'll start by voting. As you know, the debate today is should we ablate asymptomatic atrial fibrillation? So we're gonna do a pre and a post to see who's gonna be the winner of this debate. So very sophisticated system that we're gonna use. You take your right hand and you put it at the air if you're voting for this option. So the first option would be the pro option. So we should ablate asymptomatic atrial fibrillation. So who would vote for that? Excellent. And who would vote for no, we should not ablate asymptomatic AF? Okay, so Luigi has some advantage so far. And who would say I don't know? Okay. Okay. So I'm gonna start by introducing the first speaker who is Luigi DiBiase from Albert Einstein College of Medicine, and he has 15 minutes to convince the audience that we should definitely ablate asymptomatic AFib. So, good afternoon everybody, thank you for coming, Mr. Chairman, Eric, so let's have this debate. You know, as you know, the debate, sometimes you don't believe what you have to say, you have to stack with your title, but I have to say I believe what I'm going to say, so I'm not here just pretending, Eric, and these are my disclosures. So I start the debate, this is how I feel today, I'm debating a giant here, and I have to, you know, try to, try to, you know, reduce the gap. This is Dr. Przyszkowski here, walking around in his hospital, he has a nice social life, he likes sports, and everybody, you know, who doesn't know Dr. Przyszkowski, like everybody knows him. So I have to, you know, try to say, do I, can I be close to him? At least one thing I have, Eric, I got the Cardiogram News picture too, so I qualify for that, so at least try to get closer to you, although it's not easy, but I'm close to you. So, what are the issues I have with this debate? Dr. Przyszkowski, everybody call him Dr. P because he's not Przyszkowski, sometimes it's difficult to say, but maybe Eric is for me, is a mentor and a friend, so how can you debate a mentor and a friend, it's very hard, you know, he has given me a lot of advice, we didn't work clinically together, but he has been very, very instrumental in many decisions I had to make. He's a popular, successful scientist, he has been sitting for guidelines for many times, he's the former president of his society, so, you know, he influenced people, he got to choose this debate to follow, because, you know, when you follow somebody, it's easier because you know what the other guy has already said, and, you know, I met him today, he mentioned the word Godfather in a conversation we were having, and, you know, actually, we can see him, he's like the Godfather of EP, and of this High Rhythm Society, so, you know, this is what I'm fighting. He's a brilliant and challenging speaker, he's able to convince you anything he says, and more importantly, if you know him, you will learn that irrespective of what you think, at the end, he's always right, so, it's even harder now, and, you know, on the other hand, he's probably one of the Godfather that believe in sinus rhythm, I have been and heard him saying that many, many times, and today, I don't know how he had to say the opposite. He will tell me and you, and I don't know what he's going to say, but this is a prediction of what he's going to say, Luigi, come on, there are no data on asymptomatic AF patient and ablation, you need a trial on that, and I'm sure he will say that. You should have not accepted to debate me, especially on this topic, and he told me ten times since this morning, including to the chair, and I witnessed that, so, this, I win, and to make fun of me, he will say later, oh, Luigi is the only pre-fellow coming to all my courses in Las Vegas for many consecutive years, that directly went from fellowship to full professor, he has been saying that many times in many meetings, and you know that if you follow him, but he won't tell you that he does not believe in the word asymptomatic, and who better than the long fellow, Luigi, that is going to all his courses, knows and learned that, that asymptomatic is a difficult word to define, and actually, I had some publication to be here and try to debate him, and so the fact that I went to a bigger title has probably a role. So, let's go serious here, so, atrial ablation is a pandemic, and we all know it, and despite it not very clear, you can see that, you know, there is, in paroxysmal and persistent, in the last consensus document of 2024, where carotid ablation may be reasonable in selected patients, so we have a new indication in 2024, Eric, not any longer as before, and in the AFIB guidelines, we have a new word here that from 2A and in class B, in 1A, carotid ablation is recommended as first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal health to reduce symptoms, recurrence, and progression of atrial fibrillation, and that's going to be basically the core of my presentation. So, AFIB ablation progress, and we know that, and we know this also because timing matters. In 2012, we wrote this editorial where we make an analogy between AFIB and cancer. AFIB needs, cancer needs early treatment and early diagnosis. AFIB needs early treatment and early diagnosis as well, otherwise it will progress to a more complicated way, and this slide is always, you know, my presentation saying, and this area are the PV in paroxysmal, but if you wait, the procedure become complicated and we don't know what we have to do beyond PVI, but for sure, PVI is not enough. So the trial in symptomatic patient have proven that first-line therapy work. This is RF raft one, this is RF two, better than medication. We have cryo, early ablation, better than medication, and another trial on New England, early ablation, better than medication, but what we know is timing matters. There is a progression of AFIB for persistent from four to 15%, and persistent AFIB patient have a higher risk of death and stroke than paroxysmal patient, and restoration and maintenance of sinus rhythm is more difficult to achieve, including with carotid ablation in patient with persistent AFIB, as I just said. AFIB is chronic disease, persistent AFIB is associated with the worst clinical outcomes, and carotid ablation is the only way to prevent recurrence. Look at this nice paper on Jackie P. with a forehead plot here, showing all patient with AFIB, divided in two groups about the progression, the one that had an ablation and the one that did not. And as you can see here, there is a very difference between people in AFIB that had their ablation and people that do not. The AFIB progress, progress in a very, very bad way, and from the rocket AF, all cause mortality change if you have paroxysmal AFIB, or if you have persistent AFIB. So you don't want anybody to become persistent, so you have to treat all patient. This is not symptomatic AFIB. And persistent AFIB is an independent risk factor for adverse clinical outcomes, including poor improvements in the health-related quality of life. There are studies that have looked at block of the progression with ablation, not outcome. This is a test with radiofrequency from Professor Cook, and you can see that ablation prevent progression. Then we have this nice paper from Dr. Andrade, again, when you look at the progression, 75% reduction in progression to persistent atrial fibrillation with ablation. So we don't want the AFIB to progress. We want to block the progression, and the progression has consequence in the outcomes and cardiovascular outcomes. So why to stick with symptoms? We don't need symptoms. We need to block the progression of a disease. Now some patients are asymptomatic, and they have low EF in AFIB. And maybe no heart failure symptoms, but they have a tachycardia-induced cardiomyopathy. Well, this is well known, the interrelation between AFIB and heart failure, and the guidelines have changed. We wrote a nice paper, randomized, looking against ablation against amiodarone, the proof. You all know the CASTLE-AF and many other trials. So in this nice review here, we wrote about atrial fibrillation, ablation, heart failure. It's not all about styling, my darling. And Eric, I mean, heart failure patient, there's no reason to wait for the symptoms. You don't want to. You want to treat heart failure. Maybe we don't have enough data on patients in heart failure with preserved EF, but this is going to happen. But Eric, you are going to tell me, my patient has no symptoms. I learned this from you. Are they truly asymptomatic? Can you do a trial of cardioversion? You don't always know the contribution of AF to the patient's symptoms. Symptoms on AF can be subtle, especially in the onset, and restoration to sinus rhythm, even if temporary, can dictate further care. So what does it mean, asymptomatic? Asymptomatic, everybody can be asymptomatic. We need to define what this word is. And this nice review from Dr. Kalman, you know, I think, show it very well that truly asymptomatic palpitation, exertion, despair, is not what we want. The symptoms are also caused by the progression of the disease. And a lot of paper here. Now, the final part of the presentation. Do symptoms matter? Let's look at the impact on symptoms on risk. And this is a nice meta-analysis here. You can see symptomatic, no symptomatic, no difference. Garfield registry, these are non-ablation registry. These are AFib patients. This is the Garfield registry, all-cause mortality, no symptoms, symptoms. You can see. Actually, there is a difference towards asymptomatic patients. We have another New England randomized trial, the EAST-AF trial, showing that sinus rhythm therapy improve cardiovascular outcomes. So if I can improve cardiovascular outcomes, why should I decide my treatment based on symptoms? I have to decide my option based on what will be the cardiovascular outcomes. We have been misleading by older trial, by the affirmed trial, which Eric knows is not a good trial. And we know today that sinus rhythm therapy is equivalent to heart failure patient on optimal guided medical therapy. It's the same concept. We need to be in sinus rhythm. More data, this is the code AF registry. This is the freedom from death, stroke, and heart failure hospitalization between rhythm and rate, and no difference between symptomatic and asymptomatic. No difference between symptomatic and asymptomatic. And actually, this is a recent meta-analysis showing very well that patients with or without AF-related symptoms share a similar risk of adverse outcomes. So, dear Eric, my patient has no symptoms, does not change the need for sinus rhythm. Everyone deserves sinus rhythm, and the earlier, the better. The only music I like to hear in my EP lab is sinus rhythm, and I really don't think that anybody should stay in atrial fibrillation. So Eric, this is your asymptomatic atrial fibrillation patients, okay? And of course, they are asymptomatic. I mean, they're sitting on the chair. These are my asymptomatic patients after cardiac ablation. But I have to finish my part here before you, Eric, putting the ice on the cake. And you are the godfather of electrophysiology. But remember, I practice in US, but I come from Italy, and I live in New York. And there are other type of godfather that can show you the story, the movies, the legacy. And when you have a cat in your hand over there, in the neck, it's gonna be problematic for you to follow me in this debate, because I wouldn't like you to be at that position. Thank you very much. So, now we invite Eric Pistowski from Ascension St. Vincent Hospital to convince the audience that everything that Luigi said is actually not true. And we should definitely not ablate patients with asymptomatic atrial fibrillation. Before I start, I don't have as many slides, I don't need as many. So, I'm not gonna say all the things you thought I was gonna say. And me taking this side also was a little weird, because I have preached sinus rhythm, as you well know, for the better part of 30 to 40 years. I was against the firm. I didn't join it as one of the investigators, because I agree with a lot of that. That's not what the debate is, though. This is always what you do. Luigi's one of my favorite people. He did come for six years to my fellows course, six years. And then, yes, I wrote him his letter for full professorship, right from the last fellowship course he did with me to Mount Sinai. And you got your full professorship, so you owe me something. Okay, a little bit, just a little bit. And he's a terrific guy, and I send all my patients to him in New York. So, Luigi and I are good friends, and this is a, like all good debates, there's a middle ground that we'll probably come to. But the title of the debate is, should we ablate asymptomatic AFib? That has to be put in context, and that's what I hope to do. So, let me pull up my slides. How come, here, let's start. So, I'm sorry I don't have as many conflicts as my good friend. My philosophy of life is to get a few and do them big. He likes to get a bunch and do them small. So, just different concept. So, this is the actual debate. So, and I do apologize for the first couple slides, Luigi. But you know, you sort of did it to me, too. So, let's talk about Luigi when he was a little boy. So, here's the problem. You know there's an old adage, if you give a three-year-old a hammer, every object's a nail. And indeed, Luigi's mom rued the day that she gave her little three-year-old son a hammer. The problem is, the problem is when they grow up, you see, they have the same idea. So, when they grow up, they have a different hammer. In this case, it's an ablation catheter. And it seems like everyone that comes to him in New York, if they're in a wheelchair, if they've had three hours of AFib their entire life, only one episode, it doesn't matter. As far as Luigi's concerned, come to Dr. Luigi's asymptomatic ablation clinic. That is the heart of the matter. Not everyone needs an ablation, okay? And you can still hear the sinus rhythm 99.99% of the time in that patient. That's okay. So, I would like to put this a little bit in perspective, because indeed, I have someone who's pushed sinus rhythm my whole career. So, he and I are on the same page. But let's put some sense into this thing here, Luigi. So, basically, hold on a second. Yeah. So, there are certain guiding principles for all of us in medicine. And we know them. We learned them when we were in medical school. We took an oath. Primal non-necessary, first do no harm, guiding principles. And let's be fair about it. Both anti-rhythmic drugs and ablation can cause harm. I don't think there's anybody who would deny that. So, the potential benefits in patients who are not going to feel that much better. And we'll get to that point, because I don't disagree that some people think they're asymptomatic. And we'll get to that point. And they actually do have subtle symptoms. But let's talk about the broad swath of AFib patients, many of whom are actually not symptomatic. So, you have to have a benefit to incur a risk. Or you're not being a good bedside doctor. Okay. So, in that case, then, let's talk about some things that we always do. So, we know treating hypertension has documented, clear-cut benefits. Reduce heart disease, stroke, kidney disease, et cetera. Hyperlipidemia, we also know, has clear-cut, defined benefits. And what are the benefits in AFib? These are all theoretical. So, I'm sure there's a patient out there who you ablate that probably you would prevent a stroke. I mean, that's never been proved. But some of us who've been doing this for 40 plus years, I mean, we believe that. I suspect that Luigi and I both believe that. But there's no study that shows that. I mean, and we all know that you can't really stop, you know, blood thinners in many people, even after you've successfully ablated them. So, that's possible. So, that's a possible benefit. Heart failure, yeah, if they're going fast, for sure. Or if they have low EF, yes. I think there you can make a totally different call. And then there's this wonderful area of research that I've been very much following, looking at the subtle effects on the brain when you're in AFib. I think there have been some nice studies on it. It's not proved yet. But I think we've missed the boat on saying that just because it's not a stroke, it's not affecting the brain. I think there are clear-cut data points regarding dementia, still needs to be proved. So, I think there were some theoretical benefits. But like Luigi said, a study to prove those would help us greatly if we're going to not reduce symptoms. Then we have to have something to balance the risks. And he's correct. I'm surprised you didn't show this. If I were taking your side, I would have said, hey, Prostowski, you wrote an editorial saying people should be inside this rhythm. So, I'll show it to you. So, I have held this for many years. And I call it a bridge to the future. And I'll go through a little more detail. For patients who come in in persistent, and we'll get to that, persistent AFib. He and I have very little disagreement in the persistent group, persistent AFib. The discussion I have with them in the office is what I call a bridge to the future. I go over with them carefully the fact that if this persists for a long time, we may get to a point of no return. And three years from now, you may need sinus. So getting you in sinus now is a bridge to the future. And I think that's a fair discussion to have with patients. So he and I are probably on the same page there. And are there trials that have enrolled asymptomatic AFib? I only have one trial to show you. You know, be careful in any kind of debate. When somebody throws up more data than you can ever digest and they're trying to prove something, they're trying to dazzle you, razzle dazzle you. This is a legitimate trial. And I pulled out this because they did have about 30% asymptomatics. So the debate is ablation. So let's see what they used to restore sinus, Luigi. Oh, by the way, 20% ablation, 80% drug. So you said we have to ablate everybody. That's the debate. We weren't talking sinus versus AFib. We were talking about methods to get to sinus rhythm. So even the trial, you love the quote, shows that only 20% were ablated and 80% received drugs. So you don't have as much data on your side as you think. OK, and so here's that study. And by the way, we all like to quote it. But I mean, you know, the lines aren't that far apart. I mean, statistically significant, I give it to you. But it's not like, you know, made it, you know, when the lines were really far apart. But anyway, it's statistically significant. So what I'd like to do at the very end is, at least from my viewpoint, how do I personally approach this? Because you'll see we have some agreement, but not to the point he would like. I'll come back to that. All right, so this is how I look at it as a clinician in the office. So if a patient comes in, and the question is, would I use anti-rhythmic therapy? So first of all, let's break it down. If they have paroxysmal AFib and it's device-detected, the answer is no, not going to do it. I mean, it's just, I can't see a reason for doing that. And if they have a low AFib burden, yes, I know it can get ahead of you. You can get worse. That's why, as a doctor, you follow patients. You know, it's like saying, oh, you have 100-degree temperature today. Let's give you three antibiotics in case it goes up to 104 tomorrow. You don't do that. You know, you just don't do that. So you have to say to yourself, if somebody's got a 1% or 2% burden, and listen, in this room, I can, looking around, I see a lot of friends. How many times do you get a pacemaker check and you find that you've got a little AFib on there? OK, how many times do you have a link in there and you have like 1% AFib? Do you really go crazy over 1% AFib? No, you don't. Let's be honest. You don't. But I totally agree with Luigi here. And I use 20% to 25%. That's just personally from my own experience. I'm not going to sell it to you. You might like 15%. But just in watching patients over the many years, when you start to get burdens of 20% to 25%, yes, I think the course of action is they're going to become persistent. And I don't want that. And in those patients, if they're young, they get ablated unless they don't want to be. If they're relatively old, let's say they're in their late 70s or 80s, you know, you at least want to offer them the option. Maybe you want to answer with me drugs. But that group, I think, Luigi, you and I are totally in agreement with. And then we come to this group of persistent AFib. And Luigi's right. I've been preaching this for years. A lot of people think that they're asymptomatic. And they turn out, we all know, not to be. Once you cardiovert them, they do it. One of the classic cases I have, and I hate Afirm, by the way. I mean, everyone knows my feeling of Afirm. I railed against it for years. I think it harms so many people. One is a young 16-year-old in southern Indiana who came to me in AFib. And here's the story. He went to a dentist to have a tooth pulled. He was given some kind of nitrous something or other. And he went in AFib. I mean, I have no idea why. He went in AFib. And so the local doctor said, well, Afirm was there. And he doesn't need to be in sinus. Do you believe that? 16-year-old kid. So they looked up, and I don't know, three months later, they found me somehow. And they came up. And I was just, I couldn't believe it. They quoted Afirm for this little 16-year-old. Anyway, we got him back into sinus. Now, he said he was asymptomatic. So he comes back for his visit. Now he's been in sinus for a couple months. I feel great, doc. I never felt this. I mean, I just feel great. I said, wait a second. We went through all these symptoms. You didn't have any. He goes, yeah, but I just felt this thing in my chest. And maybe I just thought that was who I was. So there's no question. We've all been there. And so I think you have to prove with cardioversion and keeping them in sinus that they are truly asymptomatic. So let's say they feel better. No question. Luigi and I are on the same page there. You can do the shared decision-making, because you love that term. See, I grew up in an era in medicine where we called it being a good doctor. But now I know we do a shared. If you write in your notes shared decision-making, you basically keep yourself at bay with all the lawyers out there who are trying to come after you. Hey, I had shared decision-making. Look at the guidelines. But it's just being a good doctor. It's telling patients risk and benefits of therapy. So no question there. And would I lean to ablation? Probably. But I'd have a discussion with them. The key here is my editorial is the other part. There are patients. You may not believe me, but there are patients who you cardiovert. And they come back and say, I feel no different, doc. I don't. And if they're 86 years old, you know what? I leave them in rate control, period. But if they're younger, I will tend to have that discussion within the Bridge to the Future. And some I've ablated. And some have said, I'm fine with a drug. And most of them do want to be in sinus after hearing the discussion. So I think, Luigi, we agree there. But here's the bottom line. So Luigi, you want everyone ablated. So here's what I say. There was actually a movie. You remember Princess Bride? There's a big difference between mostly dead and all dead. He's only mostly dead. So Luigi, you're not all wrong. You're only mostly wrong. So you're not totally wrong. So in conclusion, I really do feel the majority, because you have to take the whole field, the majority of patients who come in with asymptomatic AFib, leave them alone. They don't need to be ablated. Thank you very much. OK, Luigi, now you need to convince us why we all need to come to your asymptomatic AFib clinic. I mean, I don't have the bottle slide. I have the same slide. But we agree to disagree in many points. And I just want to read the title, Eric. We should prefer carotid ablation of asymptomatic AF patient. The debate didn't say in all asymptomatic AFib patients. So I may agree with you that it's not all, but it's the majority. And you have to go to a subset of patient that after the shock really don't feel any improvement. We all know that these are really rare. Plus, I spent 10 minutes of my presentation with under the slides to show you it's not only the symptoms, it's also the progression of the disease that you have to block. The analogy with cancer comes back. If you have a small lump in the breast that is asymptomatic, do you want it removed, or you want to let it stay to progress to a later phase, where then you will need to do chemotherapy, mastectomy, and radiotherapy? You can do it with a simple procedure that is there for you. So you don't want the problem to progress. And the idea is that one episode, two episodes of AFib, it's OK. In a young guy, in an old guy, it will progress. It will become a bigger problem that you can stop immediately. So if you believe that, then these are the slides that were at the beginning, Eric, which are all slides that were saying that, yes, East AF net shows that you can achieve sinus rhythm with medications or with ablation. But how much more study we have to show you that to maintain the sinus rhythm, ablation is better than medication. Ablation is better than medication. So why, if you need to stay in sinus rhythm, you want to give this medication? We have data proving that medications are inferior to ablation to maintain sinus rhythm. So if you believe in sinus rhythm, you do ablation. If you do not believe in sinus rhythm, in the minority of patients that are old, 88, or that have no problem, I may agree with you. But everybody else deserves sinus rhythm. Thank you. So Eric, medication, ablation. Medication, ablation. I don't have any backup slides. I didn't think I needed them. So this is the problem. You know, some of you are old enough in the room to remember the famous debate of Ronald Reagan and Jimmy Carter, when he famously got up and said, because there was a lot of issue about age. Remember, Ronald Reagan was old. That doesn't seem to be a problem anymore. But Ronald Reagan was old. No politics. So anyway, and he turned to Jimmy Carter, and he said, you know, I won't hold it against you, your age, which just won the day. So I won't hold it against your age. You just need more experience. Maybe you have such a narrow view sitting near the ivory tower, and you think every AFib patient progresses. You're just wrong. You're just simply wrong. I've been doing this for over four decades. I used to think that most did. And then I went back and looked at the literature. There's a very famous article written decades ago. They tracked people for 10 years, and about 25% to 30% went on to persist it. I mean, 75% didn't. And I'm looking at some of my partners down here. And I can promise you, we all have patients that we've been following for years that are having 3%, 4%, 5% AFib, very little. And according to your theory, I assume you do personally. You may just have your fellows do it. But if you ever actually look at your pacemaker patients that have AFib, how many of them? How many of your pacemaker patients with AFib go on to persist in AFib? You can't even calculate how low that is. So it's a false narrative to sit here and say, I saw four seconds of AFib, ergo, bring out the ablation catheter. That's just a false narrative. It's just wrong. You're too smart for that. I don't get you. So let's just focus on the people who need it. And I don't have a disagreement with you there. The patients who have persisted, the patients who have high burden, it is wrong. I'm telling you, for you to think, you just have to go to the literature to think that everyone who has AFib goes on to persist it. There are tons of data to say that's just not true. And all you have to do is look in your own device clinic and look at all those patients that you write down had a little AFib and see how few actually go on. So in your case, you would take every one of my patients who have 10 seconds of AFib, and you'd ablate them. I mean, thousands of patients, even you couldn't do it. So I think we have to be realistic. Let's concentrate on persistent, and I do think we agree there, and high burden paroxysmal, I think we agree there. But you know, you've got to get off this everyone needs ablation kick. And by the way, drugs aren't evil, OK? This is a ridiculous comparison. You know how many patients I've been following on flecainide and dofetilide? I mean, for years, and I mean years. And do they have an occasional episode of paroxysmals? Yeah, maybe. So if you said, let me ask you this. If you had a patient who had one hour of AFib in a year on a drug, you call it a failure? No, you don't have to answer. If you had an ablation patient, you've ablated some of my friends in New York area, and they come back with a burden of 1%. You're like singing the praises. Is 1% burden recurrence? So these data that we have all had false endpoints, and we know it. You know how long I've been against the 30-second rule I don't even have to tell you from the first guideline I railed against it? That's what those curves are. In real life, tons of people have good outcomes with drugs. It doesn't mean I'm giving people drugs all the time. My partners in the lab know I send patients all the time. Be sensible. Have the discussion with the patient. And don't listen to this guy, OK? Even though we're good friends, and we'll remain good friends. Thank you. So thank you very much. So we have time for discussion. And first, I want to do the second vote. So let's go back with the question. Should we ablate asymptomatic atrial fibrillation? Who's pro? Oh. And who's con? About the same proportion, but more shy people, because there's less answer than before. Yeah, right. More shy people, because there's less answer than before. Yeah, very shy. They got shy. They got shy. Yeah. You don't ask the fox to guard the hens. So that's a problem with the vote. I mean, you have a bunch of ablators out there. They want to ablate everything. I think the issue, though, really, that we should discuss, because we actually do come together on a lot of points, is really how to find, how to do a study that really does take into account a truly asymptomatic, or a low burden. You could use the low burden. The problem's going to be, Luigi, that it takes forever for some of these people to get a high burden. Some quickly, but it takes a lot for the others. So I think it requires, you did right, it does require more study. You are right. You knew eventually I'd say that. But we have a question. David Wilson. When you talk about, there are some fuzzy areas, obviously, making a decision about. But one of the things you mentioned is relatively young. And I'm curious where that is now, and how that's changing for you. It changes every year for me. I'm relatively young. I didn't put a number on it for that very reason, because I go by physiologic age versus numerical. I mean, I'm looking at my guys here who I send patients to all the time. And I can tell you, if I call them and don't say anything else, and say, I'm sending you a 60-year-old, they go, hey, this is great. But that 60-year-old looks like 90. I get a quick call from them. Like, what did you do to me, Eric? And then you have 89-year-old patients who look like they're 60. So I mean somebody who's physiologically in pretty good shape. So that's why I sort of made it relatively. I accept your challenge, because every year I get older, I make the age of ablation younger. Yes. I agree with Eric. I mean, I also follow physiologic age, because some older patients are actually younger than some younger patients. What I can tell you is that with PFA and the procedure being more efficient in the duration and in the possibility of creating a damage with the RF or with cryo, you can still damage the patient with transeptin, another part of the procedure. But the energies, the average age before, when I was going from 80 to 82, 83, I was on my edge. Now, between 85 and 88, I still consider the ablation if I feel the patient relatively young. So I think PFA has increased the 10 years, the edge of my limit on when to say yes or no to an ablation. Yeah, I think you make a good point. As technology evolves and ablations are quicker and less complications, I think we should, as a field, evolve with that. I mean, if you want to look at data, Cabana said if you're over 75, you didn't derive that much benefit. I've ablated many people over 75. So that's just a number that came out of a trial, right, Luigi? It's not every patient is independent. So I think the two of us would take the same view of patient in your office. But the big problem here is we're talking about success with PVI. Yet we both agree that the big group that we agree on are persistent. And persistent results have stayed stagnant for 25 years. And I have to tell you, one of the things I'm excited by, premature a little bit, are the GLP-1 agonists, some of the early work that Jeff Goldberger is doing. Why are they doing better when they get that? The patients who had regular weight loss didn't do as well, similar amount of weight loss. So you have to ask yourself, what's the metabolic thing? Are they affecting the adipose tissue? Are they affecting healing? And I think that is something as a field we have to think about. Is it something you might say, I'll give you three months of shots before I do it, and three months after? I don't know. But we have to get past this 65% to 70% effective line, right? We just have to get past that. And I don't want to be misinterpreted. It's not that the new energy source do not have complication, but have complication that are less severe than atrial fissile fistula or phrenic nerve palsy or RF perforation. So there are complications with PFA, and we are learning them. But they are less severe into the outcome. And I agree with Eric also. What is 35 seconds of recurring a-fib or 1% of a-fib burden? Of course, as I'm not going to ablate the 1% a-fib pacemaker burden, I'm not going to consider a failure, a patient, a comeback from persistent with 1%. I mean, it's the same. No, we've shot ourselves in the foot for all these years. I was on the first guidelines, and I railed against it. I railed against the 30-second rule. I said, there's no reason for the 30-second rule. And we took a vote, and I lost. So two years later, we have the second one. I don't usually continually lose in debates, but I continually lost this debate every two years. I could not pull people to my side. I thought we were, that's OK for a statistical model, but it's not reality. I mean, who in the world would consider it a failure if one of your patients had one minute of AFib in 365 days? Come on. That's absurd endpoint, right? So we've hurt ourselves. Those curves are realistically all higher, in my personal opinion. You know, I think we just hurt ourselves. So we agree on that. And I don't know why we were steadfast on that. So we're moving also in definitions. But do you, yeah, I'm sorry. We have some questions from the iPad system. And you both agree on the persistent aspect of things where return of sinus rhythm would be a good thing. So some challenges that we're facing when we refer these patients. The first one is, we talked about age, but is there a limit of left atrial size? Yes. So left atrial size is something I really use to guide my type of procedure. So when you have a patient with LA size more than five, I have a conversation with the patient. I mean, we have experienced then this patient will not be PVI responder, okay? So you need to tell the patient, it's less likely that if I do a PVI only procedure to you, the procedure will be effective. So I need to go beyond PVI. This means I have to ablate the posterior wall. I have to ablate the coronary sinus, maybe the SVC. And in very large atrium, we have proposed the left atrial appendage as we have seen in other debates other years. So I have a conversation with the patient saying that I will do a procedure. Of course, the area I have to burn are much more than the PVI. So the possibility of reconnection of this area is gonna be higher. So most likely you end up needing two procedure. You have to tell this to the patient in front. And I will not say no. Of course, if my plan is to do PVI in a patient with LA size of five centimeters, I think the plan is wrong. The other factor that was asked is, so LA size is one. The second one is duration of the atrium. Yeah, that's more critical. I will say this though. If you have, these are old data. If you have an LA size greater than five, the efficacy of drugs just plummets unless you use Amio. And then you're really committing someone to Amio which I don't think is your best option. So there's no question if you had to go and treat them, I would take ablation with whatever the success rate is because it's really gonna beat drugs. So the question of duration is I think the most important. You know, if you get, I mean, we make, look, I was on a committee. So where do you think longstanding persistent AFib is? Do you think that's from anything other than us? I mean, we just sat around the thing. So let's pick a year. So that, you know, not 364 days, 365 days. So that's just an artificial thing we did. But there's no question, the longer they're in AFib and the more damage that's done to the atrium, the harder it is to restore and maintain sinus with ablation and certainly even harder with drugs. So there's no question. So I had a patient recently sent to me. He's been in AFib for five years. I just told him I'm not doing anything. I said, I just don't think anything will work. You have to be, you have to be straight. He sent to me because he wants an ablation. Well, I just said, I said, maybe one of my partners will do it. I doubt it. And they'll be, they're gonna be like, I'm afraid to go in my car at night if I send them there. It might be underneath my car, you know? I mean, I mean, I wouldn't do that to my partners. So why don't you agree? I mean, the chances of a good success for five years of persistent AFib. So yes, I use that, but I don't use one year as a cutoff. But if you start getting beyond like two years, I will say I try to be discouraging to the patient. But Eric, one thing, you know, I wanted to challenge is, okay, if you agree that the persistent one needs to be done, I mean, I don't think these are persistent to start with. These are paroxysmal that become persistent. Now, I agree with you that some paroxysmal stay paroxysmal and some paroxysmal progress. So an area of research that we never focus is finding ways or indicator or marker of where we can predict this patient most likely will progress and I have to do something and this patient less likely will progress. And I think this area is critical. It's ripe for research for sure because most patients actually won't progress in my experience, but enough do, it's not like 2%. I mean, 25, 35% will. Some of them have asked for implantable loop recorders and I just follow them. And when they get to like 18, 20%, these guys hear about it in the front row there, back there, because I send it to them and say, look. But with mobile devices, as they get better, I think we'll have a way to do this. You know, I know that they're not perfect yet, but they're starting to look at burden, which is kind of getting where we are. And I agree 100%, Luigi, I've not been able to pick which patient is gonna progress. And I've tried, I've looked at that for years. So I just accept any of them could progress and I keep a close lookout and like, you know my rule. So I think mobile devices will be very helpful there because you're right, you don't wanna get into the point they're in persistent, I totally agree with that. But I'm okay with a few percent. So I think we're not too far apart actually. So there are a few, do you wanna ask another question or? Yeah, there are a few questions from the audience. One is how do we clinically and objectively define if a patient is symptomatic or asymptomatic? Should we do an equality of life scores? Should we, it's just based on our medical judgment. Well, I mean, I don't use score, I talk to the patient. I mean, I understand that's a rare thing these days, but I actually talk to the patient and I have, oh, you have to have the spouse there, 100%. If you have a man comes and it's their first patient, first visit and the wife isn't there, send them home because you get no useful information. They deny everything and then you watch the spouse and you say things like, have you noticed that your husband has maybe gotten fatigued or not doing the things and they'll start piping up and say, you know, the last couple of months, he's just not as active as he used to be and there are subtle signs we can pick up on. I just really spent, I really do spend a lot of time asking them a bunch of questions. I'm sure it's not perfect, but I'd rather do that than give them some sheet of paper and say, fill it out. To me, that's not being a doctor. So that's what I do. It's not perfect, but you get a pretty good understanding of where they are. I have a related question to that. So if you say that in persistently, if you want to try to put them back in sinus rhythm, why do you care about symptoms anyway? Well, I care about, I don't care about symptoms. That's why I said- So if you want to make them in sinus rhythm, if they're symptomatic or not, if they're persistent, then just do it. Well, because that's that bridge to the future editorial I wrote. I don't care right now about them, but what if they have an MI or what if they develop heart failure? I mean, there's a lot of reasons where you might want to be in sinus, right? And you lose that opportunity if you let them go on for three years. So that's that bridge to the future discussion. You're absolutely right. At the moment, no reason. No, no reason at the moment. It has to be that arc to the future. But once they're persistent, you want to bring them back to sinus, don't you? Yes. And then you said- But not everyone. No, what if they're persistent and they're 85 years old and they're sedentary? I don't care. Okay. I really, no, I don't, I'm not nuts. I mean, he is nuts. No, I'm not nuts. My question is related to the cardioversion issue because sometimes, okay, we do an attempt of cardioversion. But then first it lasts 24 hours or less. Okay, so that's a very important point. And the second thing, if you give them antiarrhythmic drugs to see if they're maintaining, they have side effect of the amiodarone, which is- Well, you don't give me amiodarone. Why do you have to jump to amiodarone? What about dofetilide? It's a wonderful drug. It's not available in Canada, but anyway. Well, that's not my problem. So I have to move to Canada, basically. And remember, we have a problem here that's also not available in Canada. So, you know, there are trade-offs, okay? There are definitely trade-offs. So I do understand. No, I am not saying amiodarone. I don't ever do that. I will frequently, though, give them a short course of something so they'll stay in sinus. You can't have an hour and say you feel better. You gotta have at least a week or more. So I will sometimes give them a short course of an antiarrhythmic, cardiovert them, but to hope they'll stay in, and then see them back in a week or 10 days and say, how are you feeling? Is there any difference? Bring the spouse, okay? They'll often say, wow, he's doing his chores again, you know? So, but I understand what you're saying. I am not saying to give amiodarone. People always go to that. That's the last drug I give unless it's my only choice, okay, because it's just got too many side effects. And I also, I want to emphasize for, you know, the fellow in the room or, you know, the talking with the patient and your own judgment, talking to the patient, talking to the patient with the spouse. I agree with you. They will tell you, how do you feel? I feel great. And then you have the fellow with me writing the note, patient feels great, is asymptomatic, and then carotid ablation at the end, and then the insurance denial. But then I go in, I go in and I said, oh, you feel great? Yes, but can, you know, what's your energy? Well, you know, I could do three blocks, but in the last six months, I cannot do more than one block. Yeah, but you know, if you really want them to have a symptom, okay, just ask any older person, do you get short of breath climbing the stairs? And then just move on. I mean, if you just want a symptom so you can get it ablated, everybody gets short of breath going upstairs. So it's shortness of breath, climbing stairs, symptomatic AFib needs an ablation. But, you know, and the second point is, you know, the progression. So, you know, you say not everybody progress through, but I cannot, I don't know which will progress, which will not. So if I have a pacemaker, you know, I go patient by patient. Of course, I'm not doing it all, but when I have a young guy, you know, that hates, that have no symptoms, okay, it's okay to wait. But if this guy is young, but has diabetes, obesity, sleep apnea, I think he's gonna progress. Well, that's called clinical judgment. I am not up here debating, going against clinical judgment. And I know you are a good clinician. I've known you for years. I'm up here to take the side to say, take a deep breath and look at the whole picture. That was what my plan was today. Cause you know, I preached sinus rhythm for like 40 years. So I knew you'd use that against me. And you're right, you should as a debater. But I just want to put a context on it. And you're right. If somebody has 16 risk factors for AFib and they got a 5% burden, you might want to approach them much. I have no problem with that. I just want to put us back at the bedside and talk to the patient and find out who really needs it and who you can leave alone. We have a question now. Fun debate guys. So I thought it makes a lot of sense to use burden and progression as a way to stratify whether your asymptomatic patient should get an ablation. But as you know, one of the problems with asymptomatic patients is what is their AFib burden? So if you do get your non-device patient who has paroxysmal AFib, feels asymptomatic, what is your threshold in putting a loop in this person and seeing how their AFib progresses? Or if you have a persistent that you ablate, do you put a loop in afterwards and see if you got their AFib burden down to an acceptable amount? Yeah, I think those are two different issues. And a lot of groups are putting in ILRs routinely after ablation. Our group doesn't routinely, we do occasionally. I don't have a problem with if that's what you want to do. I know this is gonna sound very, I don't know what the right term is. I'll just say it. I actually tell a lot of people to go buy a watch. Be honest with you. I know it doesn't help your bottom line in your system. How come your ILRs fell, Dr. Brestowski, by 90%? Well, I told them to go buy a $400 thingamajiggy that can tell time and tell them about it. I think that's okay. I mean, I think that's one of the advances that we need to take advantage of. It's kind of what Rob Califf said today in his plenary opening. You know, we have new thing. Now, none of them work that well. We both know, I mean, two of them work pretty well and some of them don't work as well. So I try to steer them to the two that have had good data. And I say, you know, let me know when you start to see more AFib. And then maybe I'll give them a seven-day holter, try to, I don't have an absolute model, but I can promise you I don't put ILRs in most of my patients. I don't, but maybe Luigi, I may have said. No, I completely agree. I don't put ILR in most of my patients. Of course, the asymptomatic patient is the one where, you know, you start thinking about it. But at the end, you know, non-invasive way of monitoring the rhythm is also, you know, kind of good, especially, you know, after an ablation. So that is most likely if you wanna try to discontinue anticoagulation and the patient has a borderline child busk, then becomes a little bit more an issue. But otherwise, I don't think I would put an ILR in. But to your point, though, I've had two patients, both doctors, who are, they really are asymptomatic. I promise you they're asymptomatic. But they knew, one of them had read my editorial and he said, I want a loop recorder put in. And so we did, and we had this deal that when it got to 25%, he would be ablated. So it went like two and a half, three years, you know, and then it was creeping up and it got to 25. And I called him, I said, well, you're 25 now. He said, set me up. So there are people out there who know this stuff, who think it's a cool idea, you know. And I've even had patients who want me to put a second one in, because they want to continue to track their burden. So what you're saying is not wrong, it's just a different approach. And again, I think mobile devices can give you, not as accurate, but fairly decent estimates. Does rate of progression matter? They go from two to, does rate of progression matter? They go to two to 10%, but they're not at 25. Yes, that's a really good point. I didn't get into the, usually they don't, but there is a point where they jump. I don't see jumps usually like two to 3%, maybe five, but I'll sometimes see, you know, five or six go to like 16 and that concerns me. Yes, it's a really good point. But I don't want to oversell this because I don't really, I didn't do a study on it. It's really just a clinical experience, but yes, that's a very good point you raised. If I see a sudden increase, then something happened, right? There shouldn't be a sudden increase. So some of the year is changing and I think it's time to get in there and do something. So my rule is a general rule and you're correct. I will modify it depending on what I see. Yeah, it's a very good point. Thanks. By the way, the patient, the few patients you sent me, they have less than 1% of AFib, by the way. Well, I didn't send them to you to have more. I sent them to you to have less. Now, just to add on or to comment on the significant duration, like the duration of a recurrence, which is significant versus the burden, which is significant, we've studied that with Jason and Circa dose. You know, they were monitored for the whole period after that and actually the significant, 30 seconds mean has no clinical consequences. It's starting at one hour. Starting at one hour of episode duration in that trial, we observed increase in hospitalization, emergency visits and repeat ablations and cardioversions. And for the burden, it's not 1%, it's 0.1%. Actually, above 0.1%, you increase the healthcare utilizations. Yeah, I remember the figure from his paper. That's a great paper. I remember the figure from the paper and it goes to show you the 30 seconds, how silly it was. I mean, that was part of the purpose of his nice research. And the burdens were like almost on the graph, he had to use a magnifying glass to see the burdens. I thought, this is pretty good. So I would have probably not jumped quite as fast. I mean, here's the other thing about utilization. You have to tell patients not to go to the ER because they have AFib. So that's on us. And I understand a lot of them go anyway, but I always have that discussion. I say, please don't go to, here's what's gonna happen. You're gonna go to the ER, they're gonna put an IV in, they're gonna give you an IV dilt, your AFib's gonna stop two hours later, they're gonna claim it was due to the dilt and they'll come back and say, they gave me a medicine to stop, which we all know is not true. And they killed, I don't know, 10 hours in the emergency room and $5,000. I still have patients doing it, even though I tell them not to, but part of that is to educate the patient that if you're feeling okay and you just have palpitations, stay home because it's gonna go away, right? If it lasts for six, eight, 10 hours, fine, go to the ER. That's on us. I mean, we often don't actually take the time to do that and we should, so yeah, but go ahead. The last thing is what you said is actually the argument, the most convincing argument I had with my patient is I told them, listen, we can wait at the risk of you having to go back to the emergency room. I cannot predict how much this AFib will progress, but if it comes back, you may end up going to the emergency room or we can attend with the ablation. This is actually the best argument I have with American patients. I'm telling you, you know, Luigi, I'm never gonna convince you. You live in New York. I grew up in that area. You're an institution where my brother's the head of pathology. I know all about it, you know, but I still send you patients. I don't know what's the matter with me. It's because you're very good. No, we do, listen, I did one of these EP on EP shows yesterday with Melanie Truhills and she's really the best voice for patients going. I mean, she's great and I asked her a lot of questions. She says one of the biggest complaints she gets is that the patients feel we're not listening. We're not listening. So, you know, it's probably true. I mean, we have busy days. We rush through things, but the patient wants to tell their story and I'm sure we cut it off and we don't listen and we're moving on to this. So I think maybe it's time that we kind of regress back to what it means to be a doctor without a computer and I do think spending a little more time, I know it's hard on all of us. It's easier on me because I have a lesser schedule now in what I'm doing, but we need to talk to them. I mean, and if you educate them honestly about not going to the ER, I don't think they'll run to the ER. Some will, there's no question. Some are nervous and they'll go, but most won't. And then you don't have that bill and you don't have that utilization. And frankly, the patient doesn't have to go sit in an emergency room, crazy, you know, healthcare system. So I think we can do better. But in the end, let me tell you, as nutty as he is, he's still gonna get my patients who want to be ablated in New York. So you have, you've convinced me you do the right thing, even though you're not, that's okay. So I think it's time to close the session. I think that after an hour, they are almost in agreement. So we achieved something here. Thank you. Almost there. Almost, almost. So I wanna thank the speakers and thank you everybody for attending.

asymptomatic atrial fibrillation

catheter ablation

Laurent Max

Maria Terry Cabras

Luigi DiBiase

Eric Przyszkowski

disease progression

clinical judgment

EAST-AF trial

individualized care