Freezing AF gains ground in the real world?

What do you think?

I quote the link:

[www.theheart.org]

Until FIRM ablation becomes mainstream, current-day AF ablation centers on durable electrical isolation of the pulmonary veins (PVs). This can be accomplished with fire or ice. Using heat, point-to-point ablation of the PVs took years of experience and hundreds of cases to learn. Even the most skilled centers report redo-ablation rates as high as 40%. The pesky problem is gaps in conduction. It's hard to draw lines with dots. What's more, RF ablation done far from the PV orifice—or in other areas of the left atrium—creates the risk of damage to atrial mechanical function. Athletic AF patients are greedy; they want sinus rhythm and good mechanical left atrial (LA) function.

Enter cryoablation. With the release of a second-generation balloon, PV isolation with cryoenergy has made inroads in the real world. After years of experience with RF ablation, I have now done a handful of cases of cryo. Here was my thinking: as a paroxysmal AF patient myself, I would strongly consider having cryoablation. The durability of PV isolation may be superior; the risk of damaging LA mechanical function is lower; and, in skilled hands, the complication rates are minimal. The PV isolation that comes with a single freeze is impressive. Combining intracardiac ultrasound has led to lower fluoroscopy times and smaller contrast loads. I'm not alone. Many of my colleagues are learning cryoablation.


BillC



Edited 1 time(s). Last edit at 01/04/2013 02:01PM by BillC.

Cool

Bill,

Dr. Sirak, the surgeon that pioneered the Five Box procedure at Ohio State, revised the procedure earlier this year. He now uses cryoablation as well as RF ablation during the procedure. He commented that the "hot and cold" results in better electrical isolation.

EB

Hi Bill,

It's certainly good that progress is being made in Cryo technology, as expected.

But the main thing to keep in mind when reading Dr John blogs, is that for all of the interesting and useful information he sometimes posts, his viewpoint and position usually reflects that of a not so experienced ablationist. Last I heard he had done somewhere around a total of 500 or so ablations plus or minus 100 over the last eight or nine years, which isn't a whole lot.

The point being, that I can imagine why Cryo at this stage of its development seems even more appealing to such mostly PVI-only ablationists who are still moving up the learning curve and developing that muscle memory and pressure sense needed to make consistent and more reliable RF ablation lesions., than it may to the most experienced operators who have already developed a wealth of knowledge and muscle/neuronal pressure skill and dexterity needed to deliver excellent results with very low complication rates using RF catheters and which, to date, have shown superior durability compared to cryo at least in the studies and reports I am aware of. Maybe these second gen cryo tools will make it more of a winner, but only more time and confirmation will tell.

And indeed, it may not be long before Cyro evolves to the point of being widely adopted as a front line method of applying ablations even among the top tier most skilled ablationist. To my knowledge, that hasn't happened as yet. Cryo is used in certain circumstances and for certain parts of some procedures by some of the top guns ansd as EB noted Dr Sirak using it successfully in combination with RF energy in the 5Box epicardial ablations he does.

Also, in such procedures as ablating SVT in children where RF energy used so close to the AV node in a smaller heart of a child can be too big a risk to possibly ablate the AV node with RF energy and possibly make the child pacemaker dependent for life. With Cryo they can partially chill the offending SVT trigger spot part way just enough to confirm they got it, but not so low in temp just yet that is causes a permanent lesion. AS such htey can confirm they have not zapped the AV node and that they have got the right spot to stop the SVT and once that is done they can go ahead with a longer 'chill' to lower the temp enough to create a more or less permanent lesion ( at least ideally it is permanent but with Cryo that is a bigger ?? than with RF lesions.

This is a perfect example for a great application for Cryo now where nearly all Top guns will use it and would be almost imparetive for the average EP. As such, Cryo has become the standard recently in dealing with that particular case of SVT ablation in pediatric cases. But the EP will also warn the patient and parent that the lesion may not be as durable and long lasting as RF. At least if they have to do a redo later, hopefully the child has grown and has a larger heart, and/or improvements in Cryo will make it relative easy and safe to fix the SVT once and for all.

However I don't know of many elite operators, actually none that I am aware of so far, who have abandoned their cutting-edge improved RF catheters at this time, or who are considering doing so.

Its certainly a great thing if these second gen cryo catheters can even now help those with less experience, and thus less consistent results when using an RF catheter doing relatively straight forward PVI-only ablations, to deliver even better results than they and their colleagues at a broadly similar level of experience have been able to deliver with RF catheters so far. That's a real plus, if true.

But before we get too excited about Cryos possible role in the broader area of all forms of AFIB ablations, lets wait until the top guns around the world start adopting it as their own front line method of doing business!

If you are stuck now having to choose a less experience operator for a PVI, and he feels more comfortable with Cryo now, then perhaps that is the best option under such circumstances.

Still, your best option overall, if financial, travel and/or insurance issues are not a barrier, will almost invariably be to go for the very best ablationist you can find and then rely on his/her judgment on what methods will bring the greatest likelihood of long term success for you. The bottom line rule of thumb still holds, to choose the EP most carefully first, and only then consider the technology as a distant secondary issue.

My sense is that Dr John gets excited (sometimes overly so in my view) about all the new toys that come along, and for such relatively low volume operators I can certainly appreciate and understand the reasons for such enthusiasm. But until we get solid long range and larger studies showing that new gen cryo can create at least as durable lesions as RF, and with less complications such as phrenic nerve injury (which no doubt they have learned to lessen with experience and better cyro tools), then your best bet is to go for the top Docs and trust in their assessment of what really is the best for both your long term results and his!

That is always your best bet, if you can swing it, as the top methods and tools invariably will rise to the top and get adopted by the top operators around the world who invariably get to use and develop all these new toys first.

When the big boys finally jump on the Cryo bandwagon, and not mostly just the less experienced cohort of EPs looking for a easier and quicker for them to do PVI ablations, then Cryo will have more fully arrived.

Shannon



Edited 4 time(s). Last edit at 01/05/2013 05:35PM by Shannon.

I find it telling that Dr. Johnn Mandrola said in his post that, if the time comes for him to need an ablation, he'll seriously consider cryo (he has had an attack or two of AFib as well).

As an aside, as long as my TIKOSYN is working 100% I am putting off ablation and permitting the state of the art to progress.

The point that I really want to make is that all of us with AFIB should be watching the size of our left atriums. It is a short jump from paroxysmal to permanent. Ask me. I know how short that jump is. I was there and it is by the Grace of the Almighty that TIKOSYN is working so wonderfully for me and my left atrium is shrinking. The larger your left atrium the lower your chance of a successful ablation, whether it be RF OR CRYO. So seek out NSR at all costs. Supplement if it works for you (and it sure has helped me.. in fact as soon as I stopped to try and excite an AFIB attack I had skipped beats and caught two colds in a row after not having had a cold in two years). Run the gamit of meds if they work and you can tolerate them. And my feeling is.... sit back and wait as long as you have NSR and your LA is remaining small in size (normal). Mine grew in one year from under 50mm to 60mm. I am back to 55mm and hoping that another year in NSR and supplementing will see it below 50mm. Ideally, in the low 40's for an average male I believe.

If you can wait for the State of the Art to advance that is what I would do. I am in that position at the moment as fragile as it is. If TIKOSYN stops working for me I intend to go with the most experienced and most proficient EP I can find and I think I am with one of the top dozen in the world right now.... so I am just sitting and waiting for the other shoe to drop.

NSR all.

Murray L

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Tikosyn uptake Dec 2011 500ug b.i.d. NSR since!
Herein lies opinion, not professional advice, which all are well advised to seek.

I went to see Dr Steinberg who has done well over 2000 ablations and he offers both Cyro and RF with similar results at 80% paroxysmal which surprised me I thought he only did RF. He is highly regarded here in New York I also spoke to two other patients in the waiting room whose friends or relatives had successful ablations by him.
He is also doing his own trials with FIRM with 6 other EP's.
I want to see what Dr Narayan presents with his 2 FIRM presentations at the AF Symposium this month.
I've been told it will be impressive (not from Steinberg)....buts lets see.....There's lots of good things coming judging the I read from their presentation by top EP's around the world.



Edited 2 time(s). Last edit at 01/06/2013 03:33PM by McHale.

Hi Murray,
Good advice for all with regard to keeping a close watch (via echocardiography) of the LA size. And if a person is truly in NSR 24/7 long term, then hopefully there will be little progression in LA size, though there could be other factors involved as well beyond the most obvious driver of LA dilation in arrhythmia. The main issue is confirming indeed that there are no silent or sleep-time breakthroughs in even relatively short runs of AFIB/Flutter that are going on unnoticed?

If so, a person can, and often is, completely convinced they are in 24/7 NSR when that is not the case and it is more a scenario similar to that annoying knock or rattle in a car that never shows up when being monitored at the service department, but starts again after driving away from the service shop on the freeway. That is where an onboard monitor used at least periodically, and perhaps frequent checking at various times of day with that new I-Phone ECG from AliveCor could come in very handy!

Otherwise, a person could easily have a false sense of confidence that they are fine and no remodeling or LA dilation is happening even while it might be steadily, if slowly, progressing unawares.

Other than adding in that caveat that is worth verifying, you have a good plan and best of luck in getting things fixed eventually when you are good and ready and on your own terms so you can go off the drugs as well!

Shannon



Edited 1 time(s). Last edit at 01/07/2013 12:51PM by Shannon.

Shannon:
Good advice and right on the money. I was looking for breakthrough aFib and in mentioning my concerns to my EP, he ordered up a 24/7 monitor which I wore for almost a month, day and night (what a pain). It was set to respond to a button push and would record one minute before and one minute after the 'event'. It is also capable of identifying an arrhythmia or skipped beats and recording the same way. When full you transmit to the cardiology office for evaluation. I filled it up three times over the month and when analyzed the only thing they found was skipped beats.

I have to admit that during this time I was doing everything I could possibly do to induce aFib. NADA! YAY! The only thing that would induce skipped beats was high octaine coffee and low Potassium. As soon as we were done monitoring I stopped the coffee and restarted maintaining my serum Potassium at 4.5 - 5.0 (generally around 4.5). RARELY do I note skipped beats nowadays. Just NSR.

Murray L

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Tikosyn uptake Dec 2011 500ug b.i.d. NSR since!
Herein lies opinion, not professional advice, which all are well advised to seek.

Maybe that's why anti-arrhythmic drugs stop working for many people after a while is because they think they are in NSR 100% of the time, but they have night-time AFib episodes they aren't aware of that slowly remodel their heart to the point where their drug stops working. So maybe for those people who are truely in NSR 100% of the time; anti-arrhythmic drugs really will work indefinitely. Just a theory.

I would suggest that a proper course of treatment by a good EP would or should include an advanced state-of-the-art monitor every 6 - 12 months, that runs 24/7 and has autodetect. Mine detected skipped beats and presented a two minute ECG strip electronically of every "event" for the technicians to evaluate. In my case it was just skipped beats (nothing to poo-poo at but not as urgent or serious as aFib event). My remodelling reversal seems to indicate solid NSR as well and this is VERY important as remodelling while in aFib can present serious issues, not the least of which is prevention of having an ablation and/or reducing the success rate of same.

My EP has indicated that he has patients that have been on TIKOSYN for several YEARS successfully; and he also has patients that have had to come off TIKOSYN due to side-effects. Drug interactions are a huge issue with TIKOSYN and as stated elsewhere, I don't even take BEANO (simethicone) without asking if it is ok (asking the cardiac pharmacologist who maintains the TIKOSYN database and is Pfizer certified for TIKOSYN). TIKOSYN is not available from all EP's by the way - they must be certified in order to prescribe it (at least in Canada), as must the pharmacy and pharmacists; this is why it is not found in general pharmacies like, say, the pharmacy at Wegmans, etc. It is highly toxic and requires regular monitoring by a family physician to ensure kidney and liver function does not change as 80% of the dofetilide is excreted in the urine within 2 hours. At the max dosage of 500 MICROgrams b.i.d., that means that only 100 micrograms is being used. Placed on the head of a pin it would fail to cover same. After one year on the medication they may make some changes for me; reduce my Metoprolol to zero with PIP and reduce my TIKOSYN to 250ucg. b.i.d. to see if it will maintain NSR (requires a hospital stay of 3 days and is a non-urgent care issue so unlikely that it will happen anytime soon unless I can no longer tolerate side effects, in my case, fuzzy head for a couple of hours in the morning and some minor fatigue).

I believe that my EP is staying with RF ablation for various reasons and is participating in the CABANA study to compare meds vs. ablation over five years for effectiveness and cost, as aFib is set to be THE health issue of the next generation (and our generation).

Murray L

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Tikosyn uptake Dec 2011 500ug b.i.d. NSR since!
Herein lies opinion, not professional advice, which all are well advised to seek.

I just returned from my Cardiologist and one of the things discussed was ablation and the EP they hired to do Arctic Front Cyro who was initially involved in the trials in Virginia is also using RF along with Cryo. Don't know the details.
Fire and ICE...interesting as this has been discussed here before.

I think Cryo is holding its own in terms of share of total procedure. Cleveland Clinic recently reported 5% of all procedures which is the same as 4 years ago when I got a number. CCF is running nearly 6000 ablation procedures per year. Cryo biggest application by far is right sided ablations and less so for AF or anything left sided.

HI researcher,

Interesting stats on Cryo numbers not changing much at Cleveland Clinic over the last 4 years. And that the vast majority of those Cryo procedures were used in right-sided ablations is no doubt driven by the fact that the new standard of care over the last few years for SVT ablation is to use Cryo when the SVT trigger area is thought to be close to the A/V node. This is due to the fact that using RF energy in that part of the right atrium brings a greater risk for inadvertently ablating the A/V node as well with RF, and thus making the patient Pacemaker dependent for life!

This is especially true for pediatric ablations in which the smaller hearts of children make the spacing around the A/V node in the right atrium very tricky to work with with RF energy.

A big advantage of using Cryo in this application is that they can partially freeze the offending tissue and confirm they have got it right without damaging the A/V node irrevocably at a point where they can still reverse the ablation should they find any damage to A/V nodal function. Once they confirm that they are in the right spot and are safe to proceed, they then go ahead and freeze the spot all the way to create what it hoped will be a permanent lesion .. though with Cryo they warn it may not be as durable a lesion as with RF.

This very common SVT procedure that almost any EP can perform safely and that does not require anywhere near the skill level of a left sided AFIB ablation, no doubt makes up a large percentage of this steady level of 5% for Cryo ablation out of the 6,000 total ablations per year at CCF!

Once again, the fact there there has not been any jump in the number of Cryo only ablations at CCF jsut reinforces and gives credence to the wisdom to wait until .. and if .. the top gun AFIB ablationist start to switch more exclusively to Cryo before anyone here should rush out to demand your EP use it on you! The top minds and experts in this field are always going to adopt the best tools as they are proven to be so.

The caveat that Pediatric EPs tell every patient and their parents when explaining why they might have to use Cryo for their child's SVT is that the lesion may not prove as durable as it would with RF but the risks in the small heart of a child it too great to use RF if the area to ablate is too close to the AV node...

My 14 year old grand niece just had this very procedure done on her to ablate her SVT that happened spontaneously during a junior high Basketball game in Austin last month. That is why I am well up on how and when they use Cryo versus RF in such cases these days.. it seems my family genes are loaded with arrhythmia potential! .. Now its my grand niece but also my father had AFIB and died of a massive stroke at 69 in 1986 long before ablations were an option.

Also my older sister has had an AFIB ablation by a locally recommended EP in Houston, in spite of my very strong urging for her to take the short three hour drive to Austin to see Natale, but she lives in Houston and has always liked to stay close to home so she went with the guy who had 600 ablations under his belt and was the head of EP at a large local Houston Hosptial and a guy her Cardio said was 'one of the best' ( aren't they all?! . Her ablation was 9 full hours (a big red flag right there!) and she was never in NSR for long there after.

Alas, her ablation didn't work and she is in persistent AFIB even now, she also had a stroke when they were doing a hip replacement two years ago due to her severe RA and is now totally disabled and bed ridden ... a very sad story .. and no doubt one that drives my zeal to so strongly recommend people here to NOT just settle for the more convenient local EP ablation 'star', but always do everything you can to go for the best ablationist you can possibly arrange!



Edited 2 time(s). Last edit at 01/16/2013 01:24PM by Shannon.