According to the Heart Rhythm Society, by 2050, up to 16 million Americans will have atrial fibrillation (AFib), which is the most common type of arrhythmia. Ablation of atrial fibrillation continues to evolve and we are reaching a turning point in the field of electrophysiology. It is fascinating to be a part of it.
What is changing in Atrial Fibrillation treatment?
Atrial fibrillation ablation has become the cornerstone for the treatment of atrial fibrillation. During this procedure, we target the pulmonary veins and other areas that can trigger AFib. The tools commonly used until now rely on thermal energy to deliver the ablation – either heating (radiofrequency) or cooling (cryo). These technologies have proven effectiveness, but by burning or freezing the tissue, we have small risks of complications due to damage to collateral tissues.
And now we’re moving towards a new era in atrial fibrillation ablation: Pulsed Field Ablation (PFA). PFA is a new ablation technology where a very fast pulse of electricity is delivered leading to the ablation of the heart tissue targeted. This technology offers many advantages:
- This energy modality is selective to heart tissue and does not significantly increase the temperature. This means that even when ablating tissue that is in close proximity with other structures the chances of damage are very low.
- The energy delivery is fast which can reduce the procedure time.
- PFA can be delivered via different catheters that have been either custom-built or repurposed for this use. This may pace the way for the development of technologies and workflows that result in easier and more reproducible ablation.
PFA was approved in Europe several years ago, where tens of thousands of procedures have already been completed. In the US, several clinical trials have been completed or are ongoing. Some trials have already been published and led to the recent approval of two PFA technologies.
A few trials have completed enrollment and some are currently enrolling patients. And there are also several new technologies that are expected to be under investigation soon.
So what is my opinion on PFA?
If you consider the published data from clinical trials and real-world evidence (from Europe), I believe that PFA will change the landscape in AFib ablation!
In my opinion, the most important findings from the published studies that should be highlighted are:
- PFA is safe. Although not free from its own risks and procedural-related complications, PFA seems to be the solution to eliminate esophageal injury (which has not been reported in the European experience).
- PFA is efficient. Real-world procedure times have been shorter. Shorter procedure times and preparation times should improve safety and also our ability to treat more patients in the same specialized area in the hospital – the EP Lab.
- PFA is at least as effective as the current technology but because of its ease of use, may become a more effective solution.
- PFA may make it simpler to standardize the procedure and have more uniform results across multiple centers and physicians.
Although at face value one may think that the results of these studies are not spectacular, I think we should all consider carefully how impressive this technology really could be. Catheter ablation has been around for several decades and the physicians that participated in the PFA trials are some of the most experienced in the world. PFA was a new technology and doctors were immediately able to deliver ablation that was at least as effective but faster and safer in many regards. Further real-world studies have shown very short learning curves, or the number of procedures it takes a physician to achieve optimal results with a new tool or technique, and even shorter procedure times. Therefore, even though a brand new technology was being tested, results were quite good and with some clear advantages identified.
In summary, in my opinion, PFA will change the landscape of AFib ablation. The technology will advance fast ushering in a new era in AFib care. I hope that real-world results with the recently and soon-to-be-approved technologies in the US will mirror what was seen in Europe and that we will quickly learn how to improve it by leveraging data collection and collaboration!
Dr Jose Osorio
Read More About AFib:
Our AFib Clinic website was designed to educate patients on Atrial Fibrillation. Here you will learn about AFib, what causes AFib, Treatment options for afib, What is AFib ablation and what the best treatment for you may be. We will keep you updated on AFib treatment options and even diagnostic options such as the apple watch for AFib. We have extensive experience with Pulsed Field Ablation or PFA as we have participated in many clinical trials and performed multiple AFib ablations using PFA. Our Practice is in Miami, FL at Mercy Hospital. If you want to learn more about Atrial Fibrillation or AFib, please schedule a consultation with Dr Jose Osorio at Mercy Hospital in Miami, FL
Comparing Atrial Fibrillation Treatments: AFib Ablation with Radiofrequency, Cryo and Pulsed Field Ablation
If you have Atrial fibrillation and it’s impacting your quality of life catheter ablation of AFib may be the procedure of choice for you.
AFib ablation is a procedure where the goal is to try to eliminate the triggers of AFib, which most commonly come from the pulmonary veins within the left atrium. Our goal is to ablate the tissue around the pulmonary veins with either heat or cold technology to isolate the triggers.
Ablation of atrial fibrillation has been happening in the United States for a little over 20 years and many clinical trials have shown its safety. Success rates have continued to improve as the technology, technique and physicians’ experience have gotten better.
Although we have a lot of experience with ablation of Atrial fibrillation using radiofrequency or cryo technology, there is still a risk of collateral damage because the heat or the cold can transmit to structures adjacent to the heart – such as the esophagus or nerves.
How can a doctor tell if you have afib?
Atrial fibrillation is diagnosed using an ECG or electrocardiogram. You have to be in afib when the ECG is being performed to detect the condition. There are other methods that can be used today depending on your type and frequency of afib.
In the early stages of Atrial Fibrillation (Afib) the condition is paroxysmal for most patients. That means that you’re in and out of Afib and have episodes that will last a few minutes to hours and may not recur for months. This pattern may delay the diagnosis, because when you go see your primary care physician or cardiologist, your heart may be in normal rhythm and an ECG performed at that time would be normal. For many patients this process continues for months or even years until eventually the condition becomes more frequent and an episode of afib is documented.
If a patient has persistent afib, they are continuously out of rhythm. That means that any time they have an ECG performed, it will document the arrhythmia. It is therefore easier to diagnose afib in this group of patients.
How do we diagnose Afib for patients with Paroxysmal type?
In order to diagnose Afib, we need to perform an ECG or a monitor while your heart is out of rhythm. This can be done in a few ways:
- performed at the doctor’s office while you are in Afib
the technology used for holter monitors has improved a lot. We are able to send patients home today with a small “patch monitor” that is taped to the upper chest area and will record your heart beats continuously for 7 to 14 days. These devices will monitor your heart night and day and if you have an episode, even if short and asymptomatic, will document it.
Implantable Loop Recorder:
- some patients have episodes
of Afib that are sporadic but may be very symptomatic and even cause strokes. Diagnosis can be a challenge. However, if we have a high index of suspicion that a patient may have Afib, we may recommend an implantable loop recorder (ILR). These are very small devices implanted under your skin. Their battery lasts years and they will monitor your heart and if arrhythmias are detected, alert your physician.
- some patients have episodes
Pacemaker and Defibrillators:
- For patients with implantable cardiac devices, diagnosis of Afib can also be made via interrogation of the device. These devices have a memory and will record any events that may be arrhythmias.
- Several smart watches and other wearable devices can be used today to monitor your heart for irregularities. If they are detected, you may use some devices to perform a single lead ECG.
Wearables have increased the number of patients diagnosed with Afib. Patients are also being diagnosed earlier in the disease process. Not every patient that has a fib diagnosed with a wearable may need to be treated immediately and some can be monitored only until they have more spells or develop symptoms.
Atrial Fibrillation Treatment
Once diagnosed with afib, patients need to be evaluated to understand what is the best strategy to reduce the stroke risk, improve the quality of life (treat the symptoms) and slow the disease progression.
Lifestyle interventions are very important to reduce the chances that a patient will progress to overt Afib with frequent and symptomatic spells. Weight loss, exercise, reduction of your alcohol intake, quitting tobacco use and also screening for sleep apnea are all important steps every patient should take to improve their overall health and reduce chances of progression of Afib.
Atrial Fibrillation (Afib) is a condition that can impact your quality of life and cause strokes. Afib treatment should be individualized to meet each patient’s needs.
Dr Jose Osorio
Read More About AFib:
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If you have Atrial fibrillation and an increased risk of stroke, we have to reduce your risk with either medications or procedures.
If your risk of stroke is increased we will recommend that you use oral anti-coagulants (or blood thinners) that can reduce the risk of stroke significantly. These medications are widely used today and they successfully reduce the risk of stroke. The new class of medications called Direct Oral Anticoagulants do not require you to have frequent blood work or a restricted diet.
Atrial fibrillation (or Afib) is a condition that can impact your quality of life and cause strokes. You should learn about the condition and the options you have. When evaluating a patient with afib, there are important steps I always take:
- Type of Afib – Understand what type of afib
- QOL – Evaluate how much Afib is affecting your quality of life and our options to improve it
- Stroke Risk – Evaluate the individual patient’s stroke risk and deciding the strategy to reduce it
- Comorbidities and Lifestyle – evaluate what other medical problems and lifestyle choices may impact your afib
In this section we will discuss Stroke Risk Assessment
What is the stroke risk for patients with Atrial Fibrillation?
If you have been diagnosed with atrial fibrillation, it is important to understand this condition, how it affects you and your treatment options.
What is atrial fibrillation or Afib?
Atrial Fibrillation is a rhythm disorder that takes place in the top chamber of the heart. Your heart has four chambers and the top chambers are called the Atria, while the lower chambers are the ventricles. Under normal conditions your heart first contracts in the top chamber and then in the lower chamber.
Measuring and Improving Afib Ablation Success Rates
Quality improvement and collaboration with electrophysiologists have been an essential part of my professional journey. It has also become the highlight of my career.
Measuring Afib Ablation Success Rates
If you or a loved one is considering undergoing an ablation for atrial fibrillation, it is important to understand what the chances of success are. There are a number of variables that will play a role. Understanding my own chances of performing a successful ablation for each patient and how to improve it has been my life’s journey.
Like other cardiologists, I am also in a context prone to burnout.
I am aware that there is no definitive solution, but I have found a motivation that shields me from succumbing to exhaustion, and I would like to share my experience.
In my last newsletter, which I highly recommend you read, I discussed the extrinsic and intrinsic motivations of healthcare professionals and teams.
Once a patient is diagnosed with atrial fibrillation (Afib) one of our first tasks is to classify what type of Afib they have.