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Town Hall on Rhythm and Rate Control, and Catheter ...
Town Hall Rhythm/Rate Control/Catheter Ablation as ...
Town Hall Rhythm/Rate Control/Catheter Ablation as First-Line Therapy (Video)
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Hello, I want to welcome all of you to this webinar. My name is Fred Kusumoto, and this is the first of our town hall webinars. For those of you who've been following this, there have been a series of webinars that actually go through with some didactic talks, et cetera, on the use of left atrial appendage occlusion and some of the topics that we're going to mention, but tonight and actually next week, so next Thursday at seven o'clock, are going to be town hall. So we really encourage all of you who are participating in this webinar to put down your questions. I'll make sure to ask the panelists those questions so we can really have truly a free ranging discussion. Next week's town hall is really going to talk about stroke prevention, thinking about atrial fibrillation prevention, et cetera. Tonight's discussion is really going to focus on rhythm and rate control, and also thinking about catheter ablation as first line therapy and sort of who do we choose for those sorts of patients. So my name is Fred Kusumoto. My day job, I work at the Mayo Clinic in Florida. I'm the chair of electrophysiology there and have a few other roles. I'm going to have each of our speakers introduce themselves. Andrea? Yeah. Hi. Great. Nice to be here. I'm the chair of electrophysiology and academic chief at Cooper Hospital in Camden, New Jersey. Great. Thank you. John? Hi. I'm John Puccini. I'm a cardiac electrophysiologist at Duke and director of the EP section here in Durham, North Carolina. Great. And James? Hi. I'm James O'Hara. I'm the lead electrophysiology PA and technical director for implantable devices for Virginia Heart here at Northern Virginia. Super. So again, to the audience, please start putting in your questions. So through the second half of this, we'll go through that, but really I'm just going to frame this with some initial discussion and some structured questions to the panelists and we'll kind of go from there. So let's talk about rhythm and rate control. So it's really striking. If you go back to the 2014 original guidelines led by Craig January, in fact, there was no for rhythm control. There's a two-way recommendation for rate control. If you had maybe tachycardia-induced cardiomyopathy, maybe you could think about sort of rhythm control. There wasn't anything. And that has really changed dramatically with this iteration of the guidelines, really focusing sort of on rhythm control and having it have more of a center stage so that there's both a two-way recommendation for rhythm control, also a two-way recommendation for rate control. So perhaps, Andrea, I'll have you start to give the audience a little bit of sort of the evidence base on sort of why this transition from rate control only in that affirmed world and now a little bit more emphasis on rhythm control. Yeah, no. Thanks, Fred. And it's really, actually, it's been dramatic, right, even, and then it used to be a stage process with starting with rate control if patients didn't do well and then go to rhythm control. But now it's totally different. I mean, our data in recent years has really shown that the beneficial outcomes, not just feeling better, which is important, but cardiovascular outcomes, so East AFibNet, really important, rhythm control. And this study included patients who had rhythm control with, in fact, most patients had rhythm control with antiarrhythmic therapy, as opposed, as compared to just rate control and standard therapy anticoagulation if they needed it based on risk factors. But outcomes were better. Not only, and I think patients feel better if they're in sinus rhythm, most patients feel better. And I think we've begun to understand, too, better, and our guidelines highlighted, as you know, a rhythm control strategy to prevent progression of AFib, prevent this atrial remodeling, enlargement of the atrium, and more atrial fibrillation begets more atrial fibrillation. So our data, you know, shows the benefit of that, patients feel better, and we can prevent that progression. Yeah, absolutely. And, John, you and I had a sidebar discussion, I remember this vividly when we were talking about rhythm and rate control, and later as we talk about atrial fibrillation, about sort of that distinction between paroxysmal AFib and persistent AFib, and we really make far less distinction sort of with that. Do you want to just comment on sort of, is there a real difference between persistent and paroxysmal? Sort of, how do you sort of think about those different patient groups, which, you know, previously had really been separated, but, you know, it's, you know, dichotomized? Yeah, so I think there's a clear emphasis in the guideline on arresting the natural history of atrial fibrillation, or recognizing it's an arc that goes all the way from the early development of risk factors to the, you know, occurrence of microbursts of atrial fibrillation to the development of clinical arrhythmia, and that is intermittent and then becomes persistent. But those mileposts that we draw are arbitrary, and I think, for me, when I look at the guidelines, you know, a lot of people have tried to pull out, oh, well, you know, the ablation recommendations here and the risk factor modification, they all sing the same song, that it's a, unfortunately, it is a progressive myopathy and illness, and so we want to do everything we can arrest it. And so I think that's why this distinction between paroxysmal and persistent atrial fibrillation is diminished in the guidelines, because the main message is, do whatever we can to prevent progression of the underlying substrate and the arrhythmia. You know, that's such an important point, John. You know, it's so funny because, you know, first of all, oftentimes they conflate, you know, we conflate ablation with rhythm control, because that may or may not be sort of true, but it's really striking, you know, I'm an ablationist, as I know you and Andrea are, and, you know, what happens is people think, oh, it's this epic battle to be won or lost, you know, good and evil, Luke Skywalker against Darth Vader, and you and I both know, all of us know, it's trench warfare, right? Once you get that sort of diagnosis, it's a long-term relationship that is so critical and valuable, and I know next week they'll talk about sort of structures and how we can sort of do that. James, how has sort of the guidelines changed sort of your practice here in the last year or two, or tell us a little bit, you know, you're in the trenches seeing patients directly, and they're asking you questions, how have the guidelines sort of changed it with regards to your recommendations and strategies with regards to rhythm versus rate control when you see your patients? So I think one of the biggest things with the guidelines sort of helped me deep in the trenches is we finally are acknowledging the fact that, hey, there's all these things, the risk factors that set people up to be at risk for AFib that we have all sort of whispered about and talked about in the background, but it wasn't sort of out there for everybody, and I now have, you know, something I can show my patients. Look, here, we're not just focusing on just the rhythm problem, but let's talk about what got you to where you have AFib and how we can prevent this from, you know, progressing, and the emphasis on changing that progression has been, you know, dramatic, you know, over the years. You know, I started in, you know, the 90s, and in the 90s, it was here's your beta blocker and come on in, and all right, hopefully you don't go too fast, and if you do, we'll get you AV notablation, and now we're all sort of seeing the fruits of our labors, and I tell patients, you know, I believe everybody should have a shot at sinus rhythm. Whether or not you stay there, well, that's up to you, your heart, your electrical system, and, you know, sort of the luck of the draw, but if you're willing to fight, I'm willing to get there and stay there in the trenches with you and keep working on everything and moving the needle, and looking at earlier, more aggressive rhythm control, I have seen sort of the impact, you know, here in the trenches where, well, we leave you in AFib, and well, your rates are controlled. We'll see you in a couple of years, and oh, now you have a cardiomyopathy, but your rates are controlled. Okay, maybe we'll do, now it's, listen, we know where this is going to go, so here is our staged plan, and because we share so many patients with, you know, cardiology on the general and interventional side, now they see sort of the same thing from us that they have seen from their, you know, plumbing folks for so long that, hey, you have some cholesterol. If it gets worse, you're going to get a stent, and then here's how we're going to stop this, so it's been incredibly beneficial. You know, James, you bring up such an important point, you know, this notion of tech cardi, induced cardiomyopathy, you know, CAMERA-MR was a really important trial, looking at MR, etc., but what was really important about that trial, which I think a lot of people missed, is that these were people that were super well rate controlled. I mean, really well rate controlled, their basal rates were 70, they got them, you know, did six-minute walks, they were kind of in the low 90s, etc., so by any measure, effective rate control, but when they underwent ablation and returned to sinus rhythm, in fact, a significant number of them, their EFs improved dramatically, and there have been multiple studies, that's not an isolated one, multiple studies from Penn, other places, which have, in fact, shown that the great majority of our patients with, quote, tachycardia-induced cardiomyopathy in the setting of atrial fibrillation often have regular rates, but if you get rid of the atrial fibrillation, get to rhythm control in a certain subset of patients, you will then be able to achieve a better left ventricular function. I want to continue this theme before we go to questions and patient, specific patient scenarios that I'm going to have each of you talk about, really talking again about sort of the evidence base and different things we've talked about, rhythm versus rate control. Andrea, how about taking on catheter ablation as first-line therapy? What's changed now that we're going to sort of be a little bit more aggressive, I guess, with this? Yeah, and just right before I mention, I just want to highlight actually what James said, too, about, you know, we're talking to the patient, the first thing you said is talking about taking care of the whole patient, right, looking at the things that got, you know, as you mentioned, got you to where you were. It's, you're taking care of risk factors, you're, you know, modifying risk factors, and we have some great data to say do that in addition to rhythm control. So rhythm control with ablation is, you know, we uplifted that, you know, that recommendation because the data, you know, looks great. There's more and more data, so there's always a lag between the time we do our studies, the randomized studies, and comparing ablation to anti-arrhythmic drugs to maintaining sinus rhythm. You know, ablation, you know, does win out in, you know, many instances there, right? So we want to maintain sinus rhythm. Patients often, especially, you know, younger patients that are not on multiple medicines, they want to stay in sinus rhythm, and they really don't want to be on lifelong medications that don't, you know, may not be very effective, right? You know, a third of people may be effective, but you may have most people are having recurrent episodes of AFib, and then, you know, getting back to, you know, treating it early, getting it, you know, maintaining sinus rhythm early. So yes, I think, you know, that the recommendation for catheter ablation is first-line therapy. I think people can feel good about, you know, patients used to come to us, and initially we'd say try a drug or try two drugs initially, and then it was like, okay, maybe try one drug. But now, for those patients who have, you know, AFib, you know, they're probably, most of them are relatively early on, but don't have a lot of comorbidities, and this is a way that we might actually, hate to use the word cure, but we can have really high success rates in those patients, and then hopefully keep them free of needing a lot of different drugs. And then, you know, as John also highlighted before, is to prevent that progression, you know, to get them early, keep them in sinus rhythm before they start to have some atrial myopathy and atrial remodeling. So I think it's important, you know, treating early, we can offer that out. We have technology that allows us to do it better and safer than we did years ago. So all of those things that come into effect are the reasons why we elevated that recommendation and the guidelines. So let's pin everybody down. I'm going to go down the line. So who's going to be sort of that first-line therapy sort of ablation type of patient? You said young, Andrea. I'll say, so what's young, you know, right? So I hope to say a good number. Oh, I wouldn't, yeah. So I think, you know, young is not necessarily, it could be someone who's going to be a little bit older, but you know, certainly, you know, I think 60s is young now. So, you know, but I think even, you know, younger than that, obviously, is, you know, but I think it's patients who, not just young, but also if you think they have a tachycardia-induced cardiomyopathy, I mean, yeah, that's, that's, that's another reason, and they don't have to be very young. Super. John? Yeah, I think, you know, stereotypically, that person was 50, 60s, hypertension, single risk factor, but I don't think that's the case anymore. I mean, I think it's anyone who has a compelling reason to avoid aneurysmic drug therapy, including some persons with structural heart disease, and given lifespans, you know, I think a very active 75-year-old, I think that is a perfectly fine candidate for first-line ablation. So, I think, you know, that stereotypical first-line ablation patient, based upon our evidence, is now a much wider group of patients, really anyone who has a good reason to avoid aneurysmic therapy. Yeah, I agree. James, who in your, sorry, your practice, do you think about giving or recommending going to ablation early as first-line therapy, beyond aneurysmic drugs or rate control? So, I would sort of echo what, you know, John just mentioned, that I don't think there's an age that I can say, oh, well, it's 50 or it's 60, because it sort of runs the gambit, and I, even just earlier today, you know, in the hospital during rounds, had a, you know, consult with somebody who's mid-70s, who's got high blood pressure, and that's about it. And, you know, we sat and talked, and I said, you know, yes, sure, I could put you on an antiarrhythmic drug for your AFib, it's happening more frequently, but I am cognizant of, okay, well, now he's going to be 80, then he's going to be 90, and those antiarrhythmic drugs don't come without sort of a hang-up, and he's very active, you know, he plays pickleball and does all these things, and hey, this is a no-brainer for me. So, I think it all really boils down to, you know, your patient in front of you, but I do find myself more and more sort of looking at, okay, what's the collateral effect of this? How can I impact you long-term? Because really, the goal of all of this is to keep everybody's quality of life as best as possible. Yeah, and I didn't want to focus on age per se, but I do think there's some patients, if they have, you know, a lot of other things going on that they're less likely, you know, I kind of look also is, are they likely to respond to ablation? So, if they have, you know, a left atrium that's five centimeters, they're not likely to respond to anything probably, but, you know, five or six centimeters, and they've had, you know, they've had the disease process, and they've been in AFib for 10 years, and, you know, there's different things of patients who are less likely to respond. I don't go right up front to ablation in those patients, but, you know, active and, you know, not necessarily based on age, agree with that. So, conversely to this group, before we go to the questions, and again, I really want to encourage the audience, this is your opportunity to really talk to people, have your questions answered with regards to patients, because we're going to get into specific patients in just a little bit, but conversely, Andrea, John, and James, who would you recommend doing an anti-arrhythmic drug sort of first, right? Because we focused on catheter ablation as first-line therapy. Who might be the kind, what's your sort of thought process that you would say, well, maybe we'll do ablation, you know, because that is a more robust way to keep sinus rhythm, and just so that the audience knows, every single trial has been, that has looked at anti-arrhythmic drug versus ablation, although there have been discussions about hard endpoints, et cetera. When you look at maintenance of sinus rhythm, there's no question that ablation therapy is superior to anti-arrhythmic drugs, but I'd like to get some sense for sort of who are the patients that you're thinking about for anti-arrhythmic drugs. So Andrea, you first, and then John. Yeah, I guess I do offer, you know, ablation, you know, some just, it really is a decision-making process between the healthcare provider and the patient. So you offer ablation, they get their new diagnosis, you know, there's some patients who don't want to take drugs, and there's patients who want to, you know, want to, just don't want a procedure, at least not up front, and it takes them some time. So most patients here, I do offer that too, but if it's someone who, you know, is really not very active, and they have, you know, there's maybe, you know, a lot of other things going on, and comorbidities, and I don't want to, you know, cancer, or some other things that are not very, maybe amenable, or a higher risk of a procedure, those are people I would try with the drug first. Super, John? Yeah, I think, you know, there's a couple of categories of people to come to mind, but I think one group that often, you know, our colleagues don't always think about is people who just aren't great candidates for a transseptal procedure. I'm always amazed by the number of people with moderate to severe pulmonary hypertension that seems to be, you know, more and more common that come into clinic. Patients with, you know, significant functional MR, I mean, these patients, in addition to the patients with severe left atrial enlargement, are not going to be well served. And I think, you know, the other thing is people who are going through a major medical illness. You know, we've, I've even gotten referrals from cardiac clinic where, you know, there's a request for catheter ablation before someone, you know, starts to undergo chemotherapy. There is a great, you know, indication for short-term amiodarone, even to get the patient through that. And then, and then finally, that patient who comes to clinic and has four or five legitimate reasons to be dysmic, probably a good time to tap the brakes, get them in sinus rhythm, an anerythmic drug, and make sure that they're really better and it's not their, you know, severe obesity and anemia and other things that, you know, that are leading to the be dysmic. So, I think that's a few different groups of patients that I think about. James, anything that you'd like to add? Well, I think I would, you know, also add in, you know, the folks that are, you know, that we see that, okay, you've been persistently in AFib for four or five years, you know, your left atrial volume index now is, you know, 50 plus milliliters per meter squared. Your BMI is 47. I tend to steer them more towards, listen, let's put the fire out. Let's see if this works and we'll work with you step-by-step, but let's start taking some things off of your comorbidities and risks for more AFib and try to increase that long-term success before I just go, ah, well, BMI is 52. It's AFib for three years. No problem. Let's, let's talk to the doctor about an ablation. You know, James, you bring up such an important point. One is, has been emphasized throughout. This is a continual thing that you have to deal with, you know, as an ablationist does something, oh, we do the ablation, then we're done with the patient. No, it's continually to manage their obesity, to do all of those things. And the other thing that you just emphasized there, which I think is so important, we often think about it as, you know, antiarrhythmic drug versus ablation, right? They're both ways to keep people in regular rhythm, you know, each with its pros and cons as it were. So I think it's important for this audience to understand that to get back to what John was talking about originally, it's really about reducing AF burden and really thinking about that thoughtfully. And if that requires an ablation, so be it. If that requires an antiarrhythmic drug, so be it. If that requires the combination thereof, so be it. I mean, we were really, in this discussion, really talking about who might you think about doing that first on. So let's go through some patient scenarios here. We're 20 minutes into this thing. Let's go through some really tough sort of patients on sort of what to do. So I'll take the asymptomatic person, right? I mean, how many times, you know, someone has an irregular heartbeat identified at their medicine clinic and they are found to be in atrial fibrillation, they get started on anticoagulation, separate issue. You talk to them, doc, I feel great, I'm golfing 18, et cetera, sort of, what does your discussion sort of look like with that patient? And James, I'll start with you. So I tend to look for the things that maybe they're overlooking or they're chalking up to, well, you know, I'm 70 and say, hey, well, have you noticed you have a little bit less energy? Sure, you can golf 18, but are you maybe a little bit more tired than you were, say, a month ago, a year ago? Has anything else sort of changed or shifted in your life to see if there is a true symptom that is actually there? And if they're truly asymptomatic, you know, I would say, well, let's just see, what do your rates look like overall? Because maybe you don't feel it because you're fairly well rate controlled, but again, all the data says, well, even if you're rate controlled, eventually this is more than likely going to be a problem, but let's take some time, work through this. I think that tends to work the best. Absolutely. Andra? You know, sometimes I think when symptoms develop gradually, like they may not recognize it where people adjust their activity level, that it's not necessarily so obvious in their, you know, their rates may not be faster. And sometimes, you know, getting them back to sinus, they'll say, well, I didn't think I was feeling bad and now I am feeling better. So for asymptomatic patients, I always, you know, question, get them back to sinus rhythm, see if they feel any different. But now also, you know, some of the data we have really is rhythm control is better, but from other endpoints, from other cardiovascular outcome endpoints, not just feeling better. Feeling better is really important. Don't get me wrong. But I wouldn't exclude someone from having, you know, having rhythm control because they're not sure if they have great, you know, a lot of symptoms. But if they're trying to decide on what way to go between ablation and having a procedure or drug therapy, I think getting them back to sinus, doing a cardioversion is an easy enough thing to do. So you do the cardioversion. Do you give them anti-arrhythmic drugs? I mean, do you just cardio, I mean, give us, give the audience a little bit more detail on sort of your practice, because I would say the same question to John and sort of how does he think about doing these patients? So in those cases, those are usually people who are not sure if they have symptoms and they're not really sure if they want to have any invasive procedure done. And that's okay because, you know, they're just maybe recently diagnosed. So getting them back to sinus, putting them on an anti-arrhythmic drug for a short period of time, you know, might they decide to stay on an anti-arrhythmic drug and if it's working well, yeah, that's fine. But if they don't maintain sinus rhythm and, you know, want to, you know, have an ablation then, and some people need to think, and we tell people it's not 100% successful, right? We know there's recurrences. There's a chance you could have a recurrence, you know, depending on what kind, how long the AFib's been around, how much structural remodeling you have. So you might, you know, eventually it might be a combined approach. It might be that you have, you know, you need a drug later, you might need a second ablation procedure. So I don't think it's wrong to give them a drug for a while. If they change their mind and have an ablation, that's just fine too. John? Yeah, I would say two things. I think this is an area where the spousal review of systems is far more reliable than the patient review of systems. So, you know, I think that's one tip that most practitioners probably already know, but I think it's worth emphasizing. And then the second one, you know, there's a beautiful study done, I think it was called the discern study, where patients after ablation all had ILRs and there was a very measurable dose effect of the amount of AFib the patient had and the reduced amount of activity. Now, there've been some other studies that suggest this is not the case. And I think a lot of patients, when they're paroxysmal with a low burden and they claim they don't have symptoms or minimal symptoms, then when they progress the persistent AFib, all of a sudden now they feel terrible. And there's a visit in the past that says their AFib is asymptomatic and then they get labeled with that. And then two or three years later, you know, they see another physician who says, well, golly, we haven't looked at your AFib a lot. And then we get the patient with the longstanding persistent AF that was symptomatic, but now we can't help them. So usually in those situations, you know, I make a point of telling the patient or the referring physician that if they get to a point where they're in AFib all the time, that's probably another good time to circle back and see us in heart rhythm clinic to make sure everything is okay. So you bring up a really important point that I want to sort of pull on that thread a little bit, John. Tell the audience about your thoughts with regards to persistent versus... So, you know, we got that person who has the EKG with some AFib, they're asymptomatic. What do you do next? Do you tell them to get a watch and sort of check for regular heartbeats? Do you make them get a seven-day monitor, a 30-day? I mean, do you put an implantable cardiac monitor? What do you do? So again, really get into the weeds. Tell us a little bit about sort of what you're thinking about when you're seeing that patient and what you're then going to order based on some of those findings. Yeah, I think this is a really complicated topic. I have to be honest, you know, there's such a large proportion of patients with atrial fibrillation where routinely checking their rhythm becomes an illness in and of itself. I'm very loathe to recommend routine monitoring, although I think I would actually favor, you know, a device-based or handheld EKG over, you know, a smartwatch for, you know, a bunch of reasons. And I think the jury's still out on whether the AFib burden algorithm with the new Apple Watch versions is going to be highly accurate and faithful. We'll probably know soon. But I still think there's a real role for symptoms, you know, motivating, you know, routine clinical monitoring. But that's just my own view. Andrea? Yeah, you know, I do have patients and a lot of patients obviously are using their wearable devices to monitor their AFib. You know, I do tell them I think, you know, it's important that they know that if they don't see AFib, because they're also talking about anticoagulation, that's a whole separate topic, but if they don't see AFib doesn't mean they're not having AFib, you know, that the watch will look at a certain period of time and then, you know, estimate a burden because it's not looking when they're running around and getting, you know, it doesn't want to cause all these false positives. So if it's just looking every 15 minutes or so, you could be missing AFib. So, you know, using it, I don't use it to gauge anticoagulation at this point in time for people who have indications for it, but to monitor. And sometimes it's, you know, for some patients they're different. I agree with John is that a lot of patients live their life around monitoring, but also can be reassuring for some patients if they're feeling symptoms and they, you know, mark it and they can look at their EKG and see that, you know, they're not having AFib, that can be useful. So it depends on the patient. We don't want them to get crazy using their watch all the time, but I think it can be a useful tool for them. Super. James, you're the one who's getting all this information. So you have that patient that comes to you with atrial fibrillation on their EKG. You listen to their heart. It's a regular sort of tell the audience sort of what your next steps are and what you're thinking about. So, I mean, the beauty of EMRs today is they're helpful, but it's the blessing and the curse with the tsunami of information. And so I always sort of look back at EKGs and say, well, is this their first EKG in 10 years? Or did they have one six months ago? And if six months ago they're, you know, seeing an orthopedist and it's sinus rhythm and, oh, yesterday they were at PCP and it's AFib. And today it's AFib. I said, okay, it's probably paroxysmal. And I get asked every day about, but my Apple Watch says my burden is under 2%. And it never moves. And we've had people that, no, I want a patch monitor and they'll wear, you know, something, one of the patch monitors and the monitor says there's no AFib. But my Apple Watch says 2%. And I tell them, look, it is an estimate. And like every estimate, it's not designed to be entirely accurate. It's just, here's where things are irregular and it might be AFib, it might not. And I tell them, look, if you are that concerned and you notice a change in something, I would rather you use something like CardioMobile or, you know, one of the, you know, single lead ECG devices, just check it. And if it says possible AFib, that doesn't mean it is, but let me know. But I try to avoid sort of the over-monitoring just because, because if you look at all the data and all the studies, well, just checking in on somebody periodically does almost as well, if not better than take this monitor, take this monitor, take this monitor. And while I do love loop recorders, I don't want people to have them unless they actually need them. Yeah, absolutely. All true. So let's, we've talked mainly, you know, sort of implied normal structural, you know, that the patient is otherwise normal and doing well. Let's delve into some structural heart disease a little bit in the setting of atrial fibrillation and how does rhythm control sort of work? So, Andrea, I'll ask you about that person with some mitral regurgitation or tricuspid regurgitation. How does, you know, some AV valve regurgitation in the setting of AFib sort of change your management sort of one way or the other? Yeah, you know, so, you know, some of those patients may also- Or not, you know, so go ahead. Or not. They may actually, you know, also have some form of a cardiomyopathy associated with it too. And I think if anything, I would want to, you know, further want to, you know, maintain sinus rhythm and offer ablation, you know, to them. So I think with structural heart disease and, you know, with heart failure, if we're talking about heart failure in particular, there's lots of, you know, there's good data to show from, you know, post hoc analysis from Cabana, but also, you know, from, you know, CASLAF, there's good data to show that maintaining sinus rhythm can be particularly beneficial for these patients. You know, sometimes we know, we have a good idea this might be a tachycardia induced cardiomyopathy, but often we don't. And it's just someone with a biopathy, maybe they have coronary disease, maybe they have another cause, but things get worse. And why do they get worse when they go into AFib? They can, you know, have certainly some more regurgitation or their cardiomyopathy may worsen. So those are patients that I do offer ablation to. Usually there's limited drugs in patients with heart failure, so we don't have a lot of choices, you know, defetalide, amiodarone, but, you know, if they're long-term amiodarone is not the best of all solutions either. So ablation would be a really good option for these patients. Yeah, absolutely. As we have patients with heart failure, so much more difficult to take care of. And John, you were the primary author for the heart failure recommendation. So give us a little bit, not only for reduced cardiomyopathy, as we've been talking about, but also in preserved DF, because, right, there's a new recommendation in our guidelines, which are not in the European guidelines that have just come out with HFPAF. And so we're in this weird position, right, where we've been a bit more aggressive with the U.S. guidelines than the European guidelines. So give the audience a little bit of flavor and insight, because I know you know this data backwards and forwards. Yeah, I think clinical trials are really hard to do, and they don't always give you clear answers. But I think repetition in clinical trials, when you see the same result over and over, that is the most, that is a very robust and reliable thing. So, you know, take, for example, posterior wall isolation. While the majority of them have been positive, or have been negative, but there's been a few positive, that is not the case for heart failure with reduced ejection fraction. You know, even the trials that barely miss their p-value still show the same trend in benefit, and when you put all the data from those randomized clinical trials together, it's very clear that there is a reduction in hospitalization and cardiovascular death. And so I think there is a clear case for a class one indication for catheter ablation in HFRAF. Again, acknowledging that ablation doesn't replace guideline-directed medical therapy. It doesn't replace all the critical things that we need to do to, you know, work on the reversible causes of heart failure, you know, other than the arrhythmia itself. But in those patients who are appropriately treated, catheter ablation, you know, really delivers an improvement in outcomes. In heart failure with preserved ejection fraction, the data are pretty tantalizing. You know, the vast, vast majority, more than 75% of patients in Cabana with heart failure had HFPEF, and we saw those same significant association with the reduction in cardiovascular events. So not class one, because we don't have prospective randomized controlled trials for HFPEF, but I actually don't think the guidelines are aggressive at all. I think they're appropriately conservative with a very, very robust evidence base. Yeah, I agree with you absolutely completely. It is intriguing, though, that, you know, looking at the same evidence, how different organizations have come up with sort of different recommendations. But I absolutely, firm believer, obviously voted for these guidelines too, along with Andrea. So all true. James, how about you? How does sort of structural heart disease fit into the equation when you're recommending either ablation and arrhythmic drugs? You know, just your thoughts. So I would echo, you know, Andrea and John's sort of statements. And my one caveat, because we work very closely with a structural team, and we do a large volume of, you know, MitraClips and things like that. And if it's somebody that has severe MR and a flail leaflet, and they're talking about a MitraClip, or, you know, the surgery team is talking about, they're sharpening the tools and they're ready to do a mitral valve replacement. You know, I tend to tell those folks, all right, listen, we will get you on short-term antiarrhythmic therapy. Let them fix this leaky valve, this, you know, structural problem to take that extra stress off that atrium. And then once you're recovered and out of the woods from that, okay, now we're going to step back into the forefront and start talking about how can we get you off of these medicines and maybe, you know, in for an ablation. And some of them, even once they have these mitral valves fixed, their atrium sort of shrinks down. They don't have this regurgitant force. And now they go from persistent a-fib to paroxysmal, and they have very minimal episodes. And they say, listen, can I just wait? I said, sure, of course. Yeah. You know, you bring up the complementary approach. I mean, you have something in that case where let's say someone has a flail leaflet. You can get someone in regular rhythm, but it's not going to do anything for their mitral regurgitation. And, you know, that is an absolute structural thing that just needs to be dealt with and addressed. Absolutely. So now let's get a little bit more. Now that we've kind of dealt with sort of structural heart disease, we've talked about sort of the first line therapy. Let's talk now before we kind of get into the weeds about sort of the ablation procedure itself and when we would go, let's say, to AV node ablation and things like that sort of later. Tell us a little bit about your thoughts on anticoagulation because everyone says, okay, you've done the ablation on me. I'm now in regular rhythm. I feel great. I'm not having any AFib. My Apple Watch says that. Can't I stop this anticoagulation? And also, aren't there these trials that suggest that if I'm not feeling AFib that anticoagulation is just not so valuable or important? Andrea, what do you tell your patients? Yeah, as we all probably see, the patients come to the office, I want my AFib ablation because I want to get off of my anticoagulant. But we know that's not the case. We don't have data to support that yet. Yes, they maintain sinus rhythm. Will some of these patients still have asymptomatic episodes of AFib? It may be more likely if they're having episodes that they might be asymptomatic after ablation than they were before ablation. Even if they tell you, I always know when I'm in AFib, we know that's not necessarily the case. So right now, I do base anticoagulation post-ablation on whether or not they have risk factors. Whether we use CHADS-VASc scores, our classic risk factors, or 2% per year if we want to expand it to the way we define it in the updated guidelines. If they still have an indication for anticoagulation based on risk score, I would tell them, don't do this to get off of your anticoagulant. Do this for other reasons that we already spoke about. So we don't have that data. Maybe we'll have that data down the line. A couple of studies being done that may help to answer that question. But I try to dissuade them from discontinuing anticoagulation. And most people continue it. Might we have some other options later on with PRN choices with Rod Passman's study looking at that. But I think right now, I still recommend anticoagulation if it's indicated before ablation. Yeah. And they'll talk more about this next week in this town hall format. It is really that there are a number of different risk scores that look at the AF, et cetera. And stroke risk and none are absolutely perfect. All have C-statistics in anywhere from 0.55 to 0.6 range, et cetera. So all not so great. So let's get to some of the questions that the audience is beginning to ask. So John, David Ernst asks about role of AF burden as an ablation indication. And what is the significance of lowering AF burden by ablation without restoring normal sinus rhythm? So I guess that you lower the AF burden, but you're not in complete 100% sinus rhythm. What's the, give us a little sense for that. Yeah, so I think talking about AFib burden is really important because when I talk to my patients, I don't talk about time to recurrence and they don't care about time to recurrence. They want to know how much AFib they're going to have after the ablation. And so that's why I find, you know, the data that Jason Andrade and others have generated where, you know, your average response to ablation for someone with paroxysmal AF is going to be a 98, 99% reduction in the amount of AFib that patient's experiencing. That's an outcome that patients understand and so it's a good conversation. The specific question is what's the evidence for reducing AFib burden without eliminating AF? And there's actually quite a substantial amount of evidence, including from CASEL and other trials that show patients who have a reduction in their AFib burden still improve, still experience some degree of improvement in cardiovascular outcomes compared to persons who don't have reduction. And then the patients, you know, there's other evidence bases that support that as well. And our own program, it's been very enlightening. You know, I think we need more centers for treatment of advanced and end-stage atrial fibrillation and we found hybrid ablation to be pretty effective there. And what's interesting is there are patients who come in, they're still having lots of AF, but instead of being in AF 100% of the time, they're now in AF 30, 40% of the time. And they report that they're feeling much better. So I think there's actually a lot of evidence to support that. Obviously for someone getting their first ablation who has a structurally normal heart, a normal size atrium, I would hope that we're targeting more than just a reduction in AFib burden, but I think there's a lot of evidence to support that approach. Yeah, absolutely, absolutely. So there's a question here about, you know, we have some data, like for example, we think about CASEL suggesting that in fact, ablation is beneficial in patients with severe heart failure. Do we need a sham PVI procedure Imran Kassam asks. So what do we think about that, right? We all thought that pacemakers were going to be great for vasovagal syncope, and now we think cardioneuroablation is going to be great for it. So what's the necessity for sham procedures and what's the value? And do we think that that's going to be important for our, you know, pretty strong recommendation for PVI. Andrea. Yeah, so I think at this stage in all the ablations and the evidence we have now, I think we're beyond the sham. I think if we started in the very beginning, ideally to do, you know, crossing the septum, don't do anything, and then doing a PVI would have been when we first started doing ablation. But I think now it kind of would be unethical at this point to go back and do that. And I think if there was a good comparison, not sham, but some other approach or procedure, you know, I think we're beyond that now. I think I'm certainly convinced that we're doing something where we're ablating these patients and at least comparing to antiarrhythmic drugs. I think we have some data that, you know, already, you know, in that comparison, it's not sham, but I think at this point, I wouldn't go there. So there's a question about sort of heart failure and AF and correcting iron deficiency. I think it gets to what John was saying. You would do all your guideline-directed medical therapy, really critical, whatever, you know, for that heart failure, et cetera. And then, but still think about AF as sort of a reversible sort of cause for, or a partially reversible cause for their heart failure. Someone asks John, and actually I'll have John and James weigh in on this, about someone who, do you offer ablation if they seem to be having effective sort of rhythm control and they ask about flecainide and maybe an easier one, which is amiodarone. So John, you first, and then James, what does that discussion look like when you, you know, feel like when you're talking to your patient? Well, I think two separate situations. I think if it's someone in their thirties who has extremely well-controlled AFib on flecainide and they're obviously low risk to be on the medication and they're obviously going to be getting an ablation at some point in their life, it might be nice to delay their ablation for another five years if it's really well-controlled because, you know, I say this with a smile, but also with a little bit of hope, maybe in five or 10 years, our AFib ablations will be curative for many, many, many, many years. So I think that the flecainide's a different case. For amiodarone, I certainly think, although there's many patients who dwell on amiodarone, if we can avoid long-term exposure to the agent, that's absolutely critical. So I treat those two situations, you know, very differently. James? Patient's happy, they're in sinus rhythm, you know, or maybe they're not happy, they're in sinus rhythm on an antiarrhythmic drug. Sort of what does your discussion look like or feel like when you're talking to them about either continuing as is, changing their, how does that look? So, you know, I would definitely echo John's sort of statement that, well, it depends on the drug for sure, because if we're talking amiodarone, I am going to do my darndest to ensure that they are not on that, you know, long-term unless I have zero other option. I think the long-term toxicities and potential toxicities are well-documented, and that's it, that's an easy sell. Now, if it's, you know, somebody in their 30s or 40s, and it's flecainide, and they've got no other issues, and they're doing well, and they've worked on, you know, their risk factors, I think it's reasonable to sort of stay the course because at their age, maybe, as John mentioned, you know, maybe we finally moved the needle a little bit further, you know, with ablations, and we're talking about now it's more curative instead of, well, 85-ish percent, and it then gets them off of this medicine long-term. Now, if it is somebody who is younger, even in their 30s, who says, listen, this medicine's great, it's working great. However, I don't want to be on medicine. I want off of this stuff. Then I quickly will pivot and say, great, I have this thing called a catheter ablation. Let's have a chat. It gets you off the medicine. You know, we don't have to worry about the long-term, you know, taking a pill every single day and me staying awake at night wondering, well, are they actually taking it twice a day? Are they taking it once a day? Are they taking an extra one? So true. Andrea, do you ever use amiodarone? I mean, tell us, what are the clinical situations that you use amiodarone, or do you just never write that prescription? Yeah, there are, as we know, not every single patient wants ablation, and there are some people who are, you know, they're certainly, if I'm going to recommend amiodarone for AFib, which, you know, is obviously off-label, we do it all the time, it would be someone who would not be a candidate for other drugs, so probably something with, someone with, you know, either really bad heart failure or really bad coronary disease, and someone who's older, I hate to use the old, young, but maybe older or has a lot of comorbidities that their lifespan isn't going to be, you know, 40 or 50 years down the line, and again, you could develop toxicity earlier than that, certainly. It doesn't have to take 10 or 20 years, but someone who's not a candidate or doesn't want an ablation and has so many comorbidities, there's not a lot of other drugs, but difficult to control rhythm or rates, you know, I'm also not a great fan of AV junction ablation, not that we're talking about that per se, but that's a very permanent thing. I don't think that's a great solution for many patients, obviously it requires pacing. So there are some patients who, yeah, I would use amiodarone, and we do use it in people who don't really have a lot of other options. Yeah, one place where I've, you know, I guess a lot of them come to me with us where they have had a cardiomyopathy, they're on the, they've been given amiodarone, they're still in a fib, we'll cardiovert them, right? Get them into regular rhythm and get their EF better, and then we all feel better when we do their ablation. I think that that's a reasonable thing that will stop the amiodarone down the line. Short term. In many cases, it's an anatomic approach for the audience as opposed to in the older days where we really thought about trying to, you know, focus in on sort of different rhythmogenic mechanisms. Now that's a way different thing in those patients who've had multiple ablations, the PVs are isolated, et cetera, but at least as a sort of a first line type of ablation, I think most would agree with just a PVI. John, there was a question, and it's going to come up because there is now a code for it. How about doing left atrial appendage occlusion and ablation at the same time? I mean, is that something you're doing there at Duke? You know, we are certainly doing it, but in pretty special situations, someone's going to have a PFO closure and they have compelling reason not to be on an anticoagulant long-term, you know, we'll do those things. I am very excited about the American Heart Association in Chicago because I think we're going to be hearing about the results from the option trial, which I, you know, I think really will answer the question and will tell us how much we should be doing it. I think there's data that we've presented in abstract form from the NCDR, though, that shows that in concomitant procedures, the quality of the seal appears just as good, and there is no signal of, you know, worse cardiovascular outcomes or anything to be concerned about. So I think we can get a good seal in concomitant cases, you know, what the long-term outcomes will dictate as the preferred approach. I think option is going to show us that and look forward to Dr. Wozniak and colleagues presenting those results in a few months. Absolutely. Andrea? Yeah, so I think when we see that data, so right now we're not doing that routinely for sure. I think there are also, you know, potentially some, you know, payer concerns and some other reasons, you know, not to do it, but I think waiting for the trial data is going to be the most important to see. And James, how about at your place? Are they doing it together as concomitant procedures? So we're actually about to start in a couple of weeks. We haven't started just yet, and, you know, there is the payer concern. And I think for the right patient, I think it's going to be a good idea, and I think option's going to help us, you know, better identify who that right patient is. And I know a lot of the initial data sort of seems very promising. And I'm, on one hand, excited about it, but on the other hand, I'm sort of, oh, boy, here we go. Fair enough, fair enough. So in the last few minutes, let's talk about the patient who is, you know, kind of down the line sort of a while. An audience member asks about AV notablation and CRTP and, you know, or CRTP or, you know, bundle conduction system pacing. Let's go down the line on sort of who do we think we ought to do, when do you start thinking about sort of AV notablation? Is it after ablation number five? Is it after someone's atrium is gigantic? I mean, what are the things that make you think about AV notablation? And then how do you support their ventricular rate? So, John, I'll go with you first and go to each panelist. Yeah, I hate AV notablation. I think it's just catastrophic that we have to do that. I think it will be the leeches of modern medical therapy. Now, that said, I do think there are patients, especially those who are most symptomatic when they're tachycardic, and all options have been exhausted, where obviously it provides benefit, solace and improvement in quality of life. So, I think it has a place, but I think it is a procedure that we should avoid at all costs. And I think some of that is because I'm a lead extractor. And so, pacemaker-dependent patients are at risk for certain events that can really have a dramatic impact on their health and their healthcare. But avoid it at all costs. Yeah, and to emphasize that even further, and someone who is pacemaker-dependent, as you point out, and has that device change out, and all of a sudden has an infected pocket, is that disaster that I see too often, for sure. Andrea? Yeah, no, I'm also not a fan in any way of AV junction ablation. I really do dislike that procedure greatly. I can remember, actually, the very first, before we had RF, before we did the studies, EP technology studies on catheter ablation with radiofrequency energy, I did one DC ablation, and it was pretty brutal. And I kind of always have that memory in my mind. But obviously, this is different with RF. I think it's a very, very rare patient where I feel like it's indicated. And there's other problems. I mean, even when you're having surgery, you have to always think of this pacer-dependent patient, which, to me, is bothersome. Someone maybe with severe pulmonary hypertension who probably could have severe heart failure, very bad lung disease. You can't control their rates. If you're really rapid rates, they will require a device, probably some kind of resynchronization device, or either CRT or, at the very least, conduction system pacing device. But they are pacer-dependent, and that's not without problems in the future. James? Yeah, I agree with everyone's statements. I despise avian out-of-ablation. I tell patients, because I frequently get asked, well, my friend had an avian out-of-ablation, and just as a pacemaker, and I do everything I can to talk them out of it. There certainly is the appropriate patient for it, but I always explained it to them. Well, when the football game starts, you don't see them start throwing Hail Marys. You wait until you've exhausted everything else, you have nothing left in your toolbox, and then, okay, I have nothing. And that's sort of us admitting, look, we got nothing else here. And I try to get the patient to understand that, look, right now, your body's controlling everything. It's better designed than anything any engineer has ever come up with so far. And the pacemaker doesn't come without the risks, and the lead extraction risks down the line, they keep us all up at night. And sure, conduction system pacing offers a lot of promise, and in the first five years, extracting them seems pretty easy. But I wonder, as I'm sure John and many of the extractors do, well, what about 15 years down the line? What about 20 years down the line? We're trying to take a left bundle lead out. What are we leaving behind, or what are we taking with it, and how easy is that gonna be as it's in there longer? And if I can avoid it, I will do everything I can. So in the last few minutes of this, I'm gonna give each of the panelists an opportunity to kind of provide sort of their sort of take-home summary of thinking about not anticoagulation, not thinking about stroke risk prevention, not thinking about prevention, which will be next week, but really rhythm and rate control and where ablation sort of lives in your armamentarium. I know it's a big general piece, but I'll let you choose a portion. So John, you first. Gosh, yeah, it's a big ask. I'd say think about ablation as first-line therapy for symptomatic patients, patients who failed anerythmic drug therapy, patients who have tachymyopathy, and patients who have HF-REF, and I think that's today. And I think we need to figure out if AF ablation is the best course of action for asymptomatic patients, and I think we need to figure out if AF ablation is the best way to preserve long-term neurologic health. I think those are the next big frontiers, and hopefully we'll have data to figure those things out and those recommendations and guidelines down the road. Great, thanks, John. Andrea? Yeah, I think the focus on early rhythm control, and I don't know that we have that message out there, and it's early rhythm control, certainly within the first year, if not even earlier, can help improve cardiovascular outcomes, stroke, hospitalization from heart failure. So these are real outcomes, not just mortality alone, but this composite outcome can be improved with early rhythm control. And then for people to think of the whole patient and look at the progression of AFib from all the different stages, like we outlined in the guidelines, the stages of AFib, get it early, at an early stage where it is something you can prevent that progression from. So early rhythm control and ablation, certainly consider that first-line therapy, knowing not everyone is gonna want ablation. James? Yeah, I would agree. I think it's a nuanced approach, and it's hard to say, well, here's my cookie-cutter algorithm for, oh, you have AFib, do this, do this, do this, which the physicist in me would love to just, ah, here's an algorithm, we're done here. But I think it's, rhythm control is incredibly important. The lasting benefits from it are huge. And for the right patient, early ablation is an ideal path for them. And I have patients that I think, look, early ablation is the best chance for you. And they say, yeah, I'd rather just keep taking my pills. I go, hey, no problem. But it's that nuanced discussion where we present our patients with the best options and what we feel is the best data, and they're gonna decide what they're gonna decide. But I definitely find myself more often as of late trying to encourage more people to consider an ablation compared to 20 years ago, where it was, ah, you feel fine. Your rates are pretty well controlled. Okay, we'll see you in a year. Yeah, and we'll finish with that, James, because that's absolutely right. Back in 04, we were thinking of firm. That was our database that we had for all of its issues. We don't have time to sort of think about it. We were really thinking that rate control was very, very reasonable at that point in time. Really a dramatic evolution, which has been shown and really supported by the 2023 AF guidelines, thinking about rhythm control in many patients and really focusing on reducing atrial fibrillation burden. And actually the recognition, as John pointed out, that in fact, AF ablation is really our most effective way for maintaining sinus rhythm in many patients. We really have to start thinking about that sort of more broadly in many patients. So with that, I want to thank the panelists, John, Andrea, James, for just a wonderful session. Thank you to all and good night. Thanks, Fred, good night. Thanks, everyone. Thanks, Fred. Thank you, everyone. Good night.
Video Summary
In this webinar hosted by Fred Kusumoto from the Mayo Clinic, the focus is on rhythm and rate control in atrial fibrillation (AF) and the evolving role of catheter ablation as a first-line therapy. The panelists include Andrea Russo, John Puccini, and James O'Hara, who discuss the significance of early rhythm control, the evidence supporting catheter ablation over antiarrhythmic drugs, and the nuances of patient management. They emphasize that contemporary guidelines have shifted to prioritize rhythm control due to its superior outcomes in maintaining sinus rhythm and preventing AF progression.<br /><br />The panelists discuss patient scenarios, including those with structural heart disease and the management of asymptomatic AF, stressing the need for individualized treatment plans. They highlight the importance of addressing risk factors that contribute to AF and preventing its progression by considering tools like catheter ablation. The experts also explore the implications of ablation for patients with heart failure and evaluate the potential for methodologies like AV node ablation when other strategies fail. They conclude by reinforcing the shift towards more frequent utilization of catheter ablation as a valuable therapeutic option in the management of atrial fibrillation.
Keywords
atrial fibrillation
catheter ablation
rhythm control
rate control
antiarrhythmic drugs
patient management
heart failure
AV node ablation
individualized treatment
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