Electrophysiologist, Mohamed Bassiouny, M.D, Texas Cardiac Arrhythmia, covers the latest on atrial fibrillation (AFIB) ablation procedures.
our topic today is Katherine relation of digital relation. I have no relevant disclosures, and, as you all know, it different relation is the most common. Heart abnormalities effects around 3 to 6 million people in the United States. About 9% of those above 65 years of age will have 80 of the one point. The prevalence of ancient is increasing as the population ages. If you can have serious consequences if not managed well, uh, this can increase in mortality. This is data from the Framingham study that showed that over 10 years of follow up patient men and women who have a fib at significantly higher mortality compared to those who did not. Moreover, the quality of life has significantly decreased with a fear is an increased risk of stroke, increased risk of heart failure and dimensions. There are multiple risk factors for a fib. Advancing age is the most important one. However, high blood pressure and obesity are are very important to you can see from this map that the prevalence of the cave is clustered around the eastern part of the United States, and the map is very similar to the prevalence of hypertension as well as the prevalence of visit these air very strong risk factors for either. The cornerstone of the management of a fib is prevention of stroke is the most important thing, followed by rain control and prevention of heart failure and rhythm control, with achievement with 80 regulation or anti arrhythmic drugs. And finally, most recently, we're trying to avoid to prevent agent for altogether by lifestyle changes and management of this fact. So our aim today is to restore normal rhythm, and to do that, we need to understand the mechanism of a flip. So the most important mechanism and the cornerstone of is, uh, rapid firing from the bomb on debates about money means have automaticity and be are more prone to the entry arrhythmias, leading to rapid firing the triggers a few. In addition, the posterior wall have abrupt changes in the muscle fibers, as you can see, and that abrupt changes can lead to this organized conduction and initiation of Asia as if it progresses from paroxysm of persistent eighth, uh, more long term, uh, physiological changes occur that refractory period of the unusual cells decrease on. They become more prone to go out of rhythm. In addition, as the patient is, um, that a different relation and the agent is beating founder or even 500 beats per minute. Eventually, the engine scars and violates it becomes more persists, all familiar with the firm study. This is a study that was published in 2000 and two. It compared rate control, the rhythm control. You can see that the mortality between the two strategies did not significantly different, However, what you might not be aware is that this study was done before the era of Catholic revelation. Out of more than 2000 patients, only 14 patients underwent a three or eight or flatter a patient. The majority of those patients with managed were with anti arrhythmic drugs. 60% were on, um, you their own and 40% off. So even the newer drugs like Dickinson was only used in less than 1% of those species. Rhythm control is achieved in less than 62% of those patients and was significant crossover between the groups. So it's hard to judge based on that study. So nowadays we know that anti arrhythmic drugs are not as effective as a patient. In fact, they actually have serious side effects that are not trivial. They increase the risk of death. Um, present the point in Arabia's your apathy, thyroid dysfunction and more and some less serious side effects spurt. Definitely those side effects to increase the quality of life substantial. So that brings us together ablation. A lot of our patients present to us after either failing a terribly drug or operating one or not, preferring to be on an anti arrhythmic drugs. And they've been suffering. The quality of life has been really low, and they come to us for help. So we need to talk about the efficacy of Catherine. Publish. This is a study that we've done in collaboration with the Cleveland Clinic, our group in Texas cardiac arrhythmia. And we've shown that the success of defibrillation can reach up to 92% parts of Asia. The 90% even in persistent success, decreases long term president if, however, is still very acceptable in patients population that probably most likely fail, and the medication perhaps the most important subgroup of patients who would benefit from a few relations patients with heart failure. So, in a landmark study that was just published in 2018. Uh, this study compared management off patients with severe systolic heart failure in collection collection less than 35%. And patients who underwent catheter ablation had substantial decrease in heart failure. Hospitalization with that, and you can, as you can see, the curve separate nicely between medical therapy in ablation with those who underwent ablation had less death unless hospitalization from heart failure. This is, ah, patient of mine. She's an 80 year old female patient, had severe cardiomyopathy, almost end stage cardiomyopathy. She was on any of their own high dose and with their own without success. And this is her ejection fraction. Prior to invasion was 10% very low. Ejection fraction were planning to put the I C D. And and after an ablation, you can see that projection fraction completely normalized, and she's off of any of their own. And she's doing her best following here for more than six months now, and she's doing very well. Nothing is more satisfying than seeing patients who have longstanding persistent a theft. We're continuously 24 hours in a theft for years, and then the manipulation you can see that they are eight Hip, empathetic, sensitive. Uh, this is another study that's very interesting. This was published in Jack, and that study showed the benefit off regulation and patients who have heart failure who are already rate control. So in the past, we think that trade control with give you the best bang for your buck and would improve the ejection fraction that this study showed that even in patients who have rate rate control that had no ejection fraction performing a field of nations substantially improve the ejection fraction 80% increase compared to 4% of those who are medically managed. And that improvement was even higher. Those patients who had an Emory done that showed no later learning enhancement so patient we had no lady and enhancement. Around 72% of those patients, compared to 29% had their ejection fraction completely normalized after the indignation. So one important thing to think about innovation is went to refer for every revelation in the past, we used to wait until the patient multiple and the medications and become very persistent, and then we refer for If you're a bishop, however, there's a lot of data that's coming up from recent studies that shows that the sooner we sent those patients performing collaboration on them higher the success rate. You can imagine that the hardest being in the upper left agents beating 500 beats per second per minute for several months. That would lead to significant scarring in violation. The left agent and success rate of a vision decreases as we wait. So this study compared performing ablation early on within a year off developing. If you compared to waiting for 70 years and the longer you wait, the lower the success. So hi Success was performing 80 Revelation sooner than later, and based on all of the data, the guidelines have changed. The indication for a few revelation used to be that we have to wait until patient fails and the trucks. Now it's a class to a indication to go directly to in relation conditions with paroxysmal, even resistant interpretation. Another population that benefits from every revelation as patients who have tacky bread is simple. In the past, the only solution was toe put a pacemaker in those patients to allow management medication, remedial agents and a terrific drugs now nowadays, especially like patients who are relatively healthy athletes have a baseline heart rate that could not tolerate living old Asians. Those patients would highly benefit from 80 revelation on getting rid of the arrhythmias. Plus, we don't need to use a video beat, so that brings us to the ablation procedure itself. The cornerstone of a few population is isolating the harmonic basis. We said, like these are the 90% of the time. These are where the impossible the rapid firing starts. Eso isolating those veins would prevent a feel from clearing, and there's multiple technologies to achieve That. Uh, the most commonly used in the first to be uses radio frequency energy by delivering alternating current at the tip of the catheter that heats up the tissue and lead to calculate the cruises and creating a scar along the Antrim of the Poland Romania preventing conduction cristian. Today at Asian, there are other modalities that have been recently introduced, are are slow and in the past, in the beginning of this procedure, we used to use fluoroscope, mostly dependent fluoroscope p, to guide our ablation. So we had a circular capital facing the Austin off for money veins and eventually countered that we use Thio deliver their radio frequency energy and that procedure would was prolonged. Used to use a lot of radiation exposure to both the patient. The operator. In addition, we have to memorize mostly where we're building and just the successful. It was not as good as nowadays. So one thing that improved successfully significantly was electric atomic mapping systems. Those systems use magnetic fields and electric currents to accurately locate our captors. Accuracy is less than one millimeters of super accurate, and we can mostly rely on them to write our revelation. So this is a three D geometry off the heart, and then we're looking from the posterior aspect of the left atrium. You can see the four point remains is the most common ah, variety of anatomy. But sometimes you have left common, uh, pain. You have multiple right base, and so you can see that the purple is healthy tissue. But the austin is where we wanna be paid, so we try to isolate those veins. Incredibly, this is mostly an anatomical precision. And with the improvement in this mapping technology, nowadays, we can even do the procedure completely without the use of fluoroscope. So our group appointed this approach and since 2014 have been using this procedure. Animal user floors. More advancement in ablation is the improvement and Catholics technology. So in the past, captains didn't have the tip used to heat up at least two transformation. But they've introduced Catholics that can irrigate it step, and who down is that it thinks would prevent charge for informing? More importantly, recently, we have Catholics that have contact four senses. That tip that allows us to exactly know how much pressure doing, uh, type of the cattle on the walls of the left came and also deliver more beautiful baby frequency region. This is a video that shows perceived re performing in a major procedure we're plating or isolating the left veins that you can see. The Catholic can show you exactly how much pressure applying on the wall, trying to keep it between 5 to 10 dams, about the procedure that reduces the risk of preparation as well as injury to the esophagus behind card. More importantly, the Catholic, they're so accurate we can see exactly how many millimeters between each operation points and the aim of procedures not leave any gaps between each point of the fish. Even leaving one gap could lead to recurrence off a fib. This on the recovery of conduction into the vein failure of the procedure. So with this technology and the accuracy off, the patient success rate is significant. This is a typical reason chat that we do for a few ablation, the basic or the most important part of the admissions to isolate the veins on each side. But as we said, the posterior wall is also highly a Homogenic, and it's not very common for us to isolate that seawall as well. So this is a case that shows, uh, the last to get through the circular Captain. The rightful money base and you can see this was after is reading the more money you can see that the hardest in normal rhythm. Um, however, the last Katherine, which is the blue cantor or like the signals are at the bottom of the screen, you can see that this is a very rapid firing coming from those veins. And if that vein was not isolated, probably the patient going to issue. So that is why we isolate those things 90% of the time. the triggers are coming from a debates. Another advancement in mapping off atrial arrhythmia is the introduction off multi or high density Electra Economical method. So there's various categories that now has a lot of like. Several electrodes can map a lot off deliver, like met a lot of points in one application. So those cattles we can use them Thio, find out where exactly, electricity or, like, the impulses are entering and exiting from the base. So here we're using category the grid by Abbott and use software called Like It can show you exactly where the embassies air, entering and exiting from the main. So the veins. That white spot is the earliest entry into the veins, and you can see here the impulse of the local electro grams are big spikes and within seven seconds are playing the frequency energy. You see those big spikes going away, and you left with those smaller spikes, which are far few potentials coming from surround instruction, another important arrhythmias that we encounter each of flutters. Things are not uncommon in patients who have resisted aged population as well a space to acquire heart surgeries or private Catholic patient, so mapping those flutters used to take a long period of time. But now, with the high density, mapping can take thousands of points. With a few minutes, you can see that flutter is rotating around the back one of the upper chamber and going across the roof in a figure of eight matter matter and finding that critical issues that area is vulnerable and beating on that over that area in the back world. That achievement, the definition other common atrial flutter is one that dates around the micro. Analysts that, uh, flutter can be elated by connecting a line from the promoter gains to the mighty rallies but kind of identifying where you need to a blade is very important. That high density mapping helps us. So we all know that the success of age of population of patients is very high oxygenated relation. The most challenging subset of patients or those with business major population in our experience of leading or isolating the veins only needs to go success, and we've been working hard on research to find the best approach for those patients. There's different modalities. We can abrade the veins. We can also create sometimes or move isolated posterior wall. Um, Most importantly, nowadays we're looking into bank in those pages, subset of patients with resistant and longstanding precipitation. It's not uncommon to find triggers that are not coming from the more moderate, not motivated triggers. In addition, one of the key Lucille's off probation was, uh, departments of production of the Pullman debates. With the improvement of the technology, this is a large study that 27 hospitals in the US and Canada and show that if the revelation using the Contact force the newer contact force after and have substantially improved outcome. And so this compared to a bleeding, only the commodity is compared to a bleeding the commodities wishing to other areas, including the posterior wall, the or flutters assed needed. And then, by morning we introduced, you can see that the successfully improve significantly up to 80% medical success. Uh, even in the difficult subset of patients, will present a different relations in our experience, especially in patients who have non personally different relation or those who have aged participant. If it would projections with the injection with systolic heart failure, one of the most common driver of a fib is non primary being triggers. So that large study that more than 700 patients our group has e identified bleeding the nun Marie being triggers improves the outcome significantly. And if we left those not American, triggers the success. It can be as low as 30%. But by targeting the bomb on revenge is whether number Marvin triggers We can improve outcomes to over 70%. Seven the Clippers. So how do I identify those not motivating triggers? Basically, we first have laid the veins, the basic veins and the steel wall. Then we place captives around different locations in the heart, and we challenge the patient with high doses off Aysel material 20 to 30 mix with 10 to 20 minutes, and we watch for, uh, areas that can't fire and trigger a fit. So if the earliest activation is coming from close to the chrysanthemum analysis, this is a 20 Paul Catherine with approximate temples and the rest of the analysis and the system one of the C s. It is coming. The earliest activation is coming from, uh, exceed activist, um, analysis. Most likely that the trigger is coming from the SBC debt structure needs to be isolated It is coming from the CS Depends on the location it is can be coming from the CS itself or depending on the location the C s. It was coming from the process. Yes, could be coming from the septum or the media aspect of the monetary union is coming from the physical aspect of the coronary Sinus. It might be coming from neuroscience itself or from the left atrial appendage or the vein of Marshall. In that situation, if we have constant triggers, guys, let those structures. Nowadays we don't go. We don't just go after the focal trigger. But isolating the whole structure would improve the success significant here. In this case, you can see that a single extra beat coming from the proximal coronary Sinus is to triggering agents. It's not only the pulmonary veins that can trigger it, however, in the majority of patients is the pulmonary veins and mostly patients are artisanal. Asia is most of that money. Also placing the last graft in the left to be barred allows us to look at the far feet potentials coming from the left media advantage and VCR constant firing from the left. Your vantage some sometimes occasion, especially in patients who have high risk of recurrence like these patients. Or this is to have a best age or hypertrophic cardiomyopathy, those patients. It's not unreasonable to isolate the future. Um, perhaps another important enhancement in emerging is the card of memory. Not only that, it just the size of the left atrium and the anatomy of the veins, but can also allow them to see the scar tissue stick extent off our tissue, the left HTM And that would help us to plan ahead. The Post Patient. So, as I told you, like delivering definitely difficulty energy to isolate the veins is the most important thing. And, uh, newer technology like ablation index allows us to deliver enough energy to isolate the veins without causing complications so that can allow us to get beautiful isolations of harmony. Bates in 19 4% 6% administrations improving the success. So over the past recent years, we've had new ablation modalities. Uh, there's a cry balloon laser or using radio frequent. Those modalities are aiming thio improve the success of the procedure and also, uh, visibility and make it easier to report. So the cry balloon is a balloon that can be advanced into the Austin of the colony veins and then liquid nitrogen produced to pull down the entrance, leading to isolation. And initially, this balloon was mostly using participative relation. However, there is promising studies that you can also work in patients with resistant in relation success the freedom from every appendage up to 80% using the balloon, especially in parks with information. A newer balloon is one that delivers radio frequency energy. There's 10 electrodes that can deliver simultaneously liberated because energy circumferential e you can also uptight place downtown. Trade the energy according to the location of the balloon. And so we kind of use less energy along the posterior aspect of the former event. Avoid injury after frantic work on our group has been involved in the studies. You gotta waiting that matter. We are actually, or the first one who did the first patient, the United States. Um, perhaps the most promising technology is just field ablation of the providing this. The new technology is being developed, and it uses sub second electric fields to a blade. The more money veins, um, the technology is based on the fact that myocardial cells or heart tissue is more sensitive to that sub second electric field compared to the surrounding structure. So you can safely isolate the pulmonary veins without injuring the frantic nerve or anyone else suffocates. That would significantly improve our outcomes and also the safety. So we're trying to decrease a complication as much as possible. Eso we use ultrasound for guidance to get access into the veins that has significantly decreased our building complications. So we do all our procedure on interrupted order Exc regulation are reading rate is less than 1%. We also use intra Codec echo to guide our ablation. It allows us to exactly pinpoint where we're gonna cross. The transept of function also allows us to see visualized the lapsed Catholic circle Catholic also the pulmonary veins and allow avoid a bleeding inside deep inside the veins and have good content. And so used to this couple Marvin's to know that our problems we can also use the I scattered to visualize the appendage in some occasions and ruled out the presence of, uh, loss. In fact, we've been covering We're using the ice cattle to guide delivery of the watchman device where we're standing on isolation of the advantage or for the tree two degrees, there's construct. We can also detect complications like Carter preparations early on on manages quickly. This is actually a huge for my, uh, recording infusion, and it wasn't a complication. It was basically recording fusion that was noted instantly in a patient with an station and sees at the time of innovation. And it actually improves significantly have to performing a tradition. Another serious complication is injured to the esophagus behind the left eight year, and that can be a different competition. However, it's very there's probably one in 1000 rate. And we've been using this multi electrode, uh, temperature probe to measure the temperature throughout the esophagus and ended up into the patient. We find this significant. So in conclusion, if relations successor improved significantly over the past several years with investment technology and, uh, doing which substance of patients will benefit more, the success rate is higher, impatient with approximate population. But more importantly, those with resisted relation can. Also, there are benefits. However, the earlier we perform the invasion patients who have stomach heart failure, uh, with benefits significantly with reduction, heart failure, hospitalization and mortality. A swell as those patients with Thank you, Brady. Single camp it within a few vision instead of facing in basement. Thank you very much. Thanks. I want you.