Update on AF Symposium and upcoming AFIB Report issue

Hi All,

I'm writing this from Orlando Florida having just completed the big annual international 'AF Symposium 2016' held here with a very big field of top EPs from around the world presenting all the latest insights from research and technology developments in this exploding field of understanding core AFIB associated contributors and possible causal relationships as well as the latest in therapeutic strategies, methods and new tools to look forward to both now and in the near future.

I've gathered a good collection of new insights and tips to share with you all in the next upcoming AFIB Report issue that I will work on non-stop from my return to Sedona on Wednesday until published around the 11th to12th of February.

I will be attending as well the EP Live 2016 training seminar in the first few days in March as a two-day intensive ablation-oriented training conference held every two years in Austin with a host of both young up and coming new EPs guided by the most experienced EPs from the US and Europe. And all being guided through numerous live ablations and LAA procedures, where the team doing each procedure shares the details of each step in real time with the audience watching on many LCD screens stretched across the front wall of the Amphitheater at St David's Medical Center. Those of us watching the procedures in the amphitheater can field questions via another top EP in the room with us acting as MC who is both asking and helping to answer those questions from the audience to the operators in each given procedure.

This is a very fascinating and very hands-on type educational event and really helps me to glean so many nuances involved in the whole process of AFIB and various ablation techniques. There is really no other way for a person in my position to hear and better understand such insider details ... And all the better to be able to share with all of you these many gems of understanding as any of us approach such a procedure and afterward during recovery etc.

The following week I am planning, if all goes well, to wrap up my travels for a while with the ISLAA (International Symposium on Left Atrial Appendage) 2016 in NYC in mid-March at yet another fabulous conference including a blend of Cardiac Surgeons, Interventional Cardiologists and EPs focusing almost exclusively on the wide array of issues and new discoveries around the LAA and its pivotal role in so many AFIB cases at some point in the history of ones AFIB. Its a huge issue with tremendous focus and innovation occurring right now and there is no better way to keep up with the cutting edge recommendations and future directions than here at this conference.

With this wealth of new inputs, the next three issues of the newsletter will each have a couple of typical summaries of studies or randomized clinical trials, and the rest of each of these three issues will include the latest relevant insights from these three events in a timely manner.

I hope to have the all three issues out by first week of May, with the first one out by end of first week of February, the second by first week of April and the third by early May and thus help close the current publication date gap to the point that we should catch up to our normal schedule around the June/July issue.

This targeted publication schedule is still subject to our progress on the website redesign effort which is moving along and we now have a nice new Logo and graphic design with which to apply the new structure of the website in the coming next few months. Its a busy time and exciting too, but as a novice in revamping a website as large as ours, I'm learning as we go all that is involved in realizing the full project.

Travis Van Slooten has been a huge invaluable help and will soon mostly take over the coding aspects of the new site, hopefully in the next month after I finish the latest newsletter. Another of our forum members, Que, who is an expert web designer as well has offered to help review and contribute to the design as we reach this next phase and I appreciate very much his help as well.

That's the plan folks, and wish us luck on this ambitious but exciting period during which we give birth to a new version of our little Oasis in the online AFIB universe!

Finally, I would be remiss if I didn't mention a real treat and highlight for me here in Orlando, was being able to meet Florida forum members JohnB and his lovely girlfriend ChrisK as well as Ken S.

Both JohnB and KenS are Natale alumni and I was pleased to be able to get a day pass for them all to the conference where they had a chance to meet up with Dr. Natale and update how they were doing to him, in addition to taking in some fascinating talks and debates by panels of the very best EPs and AFIB scientific researchers in the field.

After talking to JohnB, his very sharp gal and ex-nurse ChrisK, and KenS on the phone numerous times over the last couple of years, it was a real pleasure to get to know them all in person!

Be well,
Shannon

Phew, Shannon - You are one busy person! Thanks for all your great news. Fantastic opportunity. We are fortunate that you'll be sharing with us all of the latest.

Best to you,
Jackie

Wow, Shannon! You are sure a busy guy! I can't wait to read your new reports, this is all very exciting.

Louise.

Hi All,

My partner, Chris and I were very, very happy to attend the AF Symposium in Orlando, due to the kind efforts of our Shannon in wrangling guest passes for us for a day of great meetings. KenS was with us there to complete the "Florida contingent" of Natale alumni at the conference. Ken and I have been getting together for lunch a few times for barbeque, as we live near enough to do so.

The meetings we attended were awesome, fun, and extremely enlightening. The field of afib oriented electrophysiology is on fire with new knowledge, techniques, and hardware. This is outstanding news for all of us here. I am convinced that very real strides are being made to better address the challenges presented by being faced with afib.

Shannon remains the BEST forum admin I have ever interacted with, beside being one heck of a great guy.

Thank You, Shannon, Dr. Natale and all the great presenters we listened to while we were there in Orlando.

John

Very interesting, gentlemen.
Given these two excerpts:

Quote
Shannon
...exploding field of understanding core AFIB associated contributors and possible causal relationships as well as the latest in therapeutic strategies, methods and new tools to look forward to both now and in the near future.

and

Quote
JohnB
The field of afib oriented electrophysiology is on fire with new knowledge, techniques, and hardware.

if one is not overly burdened with afib... but was contemplating a Natale ablation sometime in the next 12 months or so... would you suggest that person wait until the end of that window so as to take advantage of these new strategies, methods, and tools? If not, why not?

Note: by "not overly burdened", I am implying that the "better treat it now before the heart remodels and it gets worse and more difficult to treat" argument is not applicable in this scenario.

Cheers,
-Ted

The key reality in my experience Apache is to live in and for the present. This 'explosion' I speak of has been going on for the last ten years in AFIB research.

One thing that was obvious too there was how much at the forefront Natale's group has been all through this time... Two years ago only Dr Natale, Haissaguerre/Jais and Univ of Penn were really focused on Non-PV trigger ablation beyond the simplist paroxysmal AFIB. Now this year it was the most common topic by a whole host of EPs just now staring to catch up to the lead Natale and Bordeaux have been pioneering for years.

And LAA/CS isolation that only Natale did at all a few years ago, has rapidly gained many more converts with a large scale change toward realizing that for persistent and long standing persistent AFIB, addressing these common elephants in the room is essential for long term success with these more challenging cases.

The other improvements are largely incremental and most all of what was presented is available now in the form of a few new catheters and continued evolution to mapping systems etc. I'll go into the most interesting avenues in the AFIB Report, but trying to time when you think the next watershed 'breakthrough' will appear on the scene and time an ablation based on such a speculative timing hunch is the single best way I know of to insure a far greater likelihood of getting stuck in the procrastination merry go round indefinitely until you flip into persistent AFIB for real!

We will NEVER be able to time such an effort by anything more reliable than shear chance. If a person has enough AFIB now to warrant considering an expert ablation process
now by an elite level maestro, then by all means stop beating around the bush while the structural remodeling is progressively taking over your left and right atriums and making the whole process that much harder.

Both JohnB and Ken could recognize in the panel talks with a group of the most elite operators in the world on the same stage, and with Natale and Haissaguerre sitting right next to one another on the panel, the genuine respect and leadership Dr N. has rightfully earned among his peers at the cutting edge of this field... One more confirmation that when choosing him, or one of his protégés, as one's ablationist insures that you will have only the best quality knowledge, experience and top of the line equipment used in your case.

The great good news now is seeing so many more frontline EPs starting to get the message too and who are now beginning to expand their treatment horizons and add to their toolkits for helping a much larger class of afibbers than they could address successfully previously. It will still take a few more years for greater experience doing non-PV trigger ablations to improve outcomes with more challenging cases among these new converts outside of the leadership groups doing this approach for years now especially with Natale's pioneering efforts here. Yet it's very good to see slowly but surely the tide turning toward greater understanding about how to improve persistent, LSPAF and advanced paroxysmal cases.

If you have infrequent short duration AFIB and are able to reduce it to a bare minimum with nutritional and life style risk factor modifications then by all means do so. But if the number of episodes is not greatly reduced in number and intensity after 6 months to a year of truly dedicated efforts at self health improvement, then waste no more time at all getting an expert ablation process underway ASAP while continuing all the healthy living habits for the rest of your life.

Trying to chase technology promises via procrastination and constantly holding out for what appears 'might' be the next brass ring, amounts to going after fools gold, and the odds become very high that one will live to regret having taken that approach when they wind up having waited too long to add the often key peice of the puzzle to their equation. You will never see it coming, until you flip into persistent AFIB as that shift happens in an instant and you will only recognize it in hindsight.

I understand your question and thought Apache, but this is an evolutionary step forward we are witnessing in the field ... Not revolutionary. And the key messages from most of the research presented is already available at the leading ablation centers now.

A lot more details and specifics will be shared in the next few AFIB Reports.

Shannon



Edited 1 time(s). Last edit at 01/19/2016 12:40PM by Shannon.

Apache, I think the cross over point came a year ago at the 2015 symposium when John Day of Intermountain showed that it was riskier to remain in AF compared to getting an ablation based upon his analysis of AF patient dementia data that they have collecting for many years at Intermountain. The topic of dementia is hitting me particular hard at the moment, my best tennis friend MRI scans came back yesterday and the news hit me like a ton of bricks.

Dear Friends,

There isn't anything I can add than Shannon hasn't already stated about the Afib Symposium in Orlando.

I hope you all realize what a wonderful advocate he is for us all.

Shannon reached out to both John B and me last week and asked if we would like to attend the conference. Due to schedule, I was only able to attend the last day, Saturday. The first panel discussion began at 7:00 a.m. and there was never a boring moment. It quickly became clear how much respect that all of the world leaders in this field give to Dr. Natale, his experience, training and opinion. He was quick to address any questions that arose. Even the panel of experts often deferred to our own good Dr. Natale.

The schedule was very business like and there was not any haggling around or late starts. I was impressed with how well it was run.

Dr. Natale exited the stage and Shannon was kind enough to get his attention so that I could speak with Dr. Natale for a few minutes. He was very gracious with his time.

All of the discussions/presentations on Saturday were information filled and thought provoking. I enjoyed sitting through them all.

Shannon is such an awesome person.......I would not have missed the opportunity to see finally meet him in person for the world........I would have had to be on my deathbed or something similarly important! I am so impressed by the care that he has for everyone that passes through this forum. He is so free with his knowledge, time, advice and genuine good nature. Thank you Shannon, for all you do, not just for me, but for all of us!

I have had lunch with John before but had never met Chris, his partner. She is a very pleasant lady. I hope he brings her to our next lunch meeting soon!

If any of you ever have the opportunity to attend a similar event, I would encourage you to do so. I think you would find it refreshing to see the nature of care and hear the discussions conducted by the most knowledgeable people in the world in this business. It might make you think twice about your local doctor! Additionally, I know you would find your time with Shannon to be pleasant!

Best wishes to all!

Sincerely,
Ken S.

AF progression measurements over a 12 month period - Randomized cohort of watchful waiting (with medications) vs ablation vs healthy cohort control.

[www.heartrhythmjournal.com]

Also see editorial comment on article.

Thanks Researcher.
Do you have a link which isn't behind a paywall? (I'm guessing you might, as you refer to editorial comments relating to the article).

Also, the "high-burden" adjective from the article title "Progression of atrial remodeling in patients with high-burden atrial fibrillation: Implications for early ablative intervention" sounds like it may not apply to the scenario I was describing. Unfortunately the abstract provides no clarification of "high-burden".

As I read it AF burden ≥10%.

Result

Group 1 demonstrated significant deterioration in total LA strain (26.3% ± 1.2% to 21.7% ± 1.2%, P < .05) and increases in Pmax (132 ± 3 ms to 138 ± 3 ms, P < .05) and Pdis (37 ± 2 ms to 42 ± 2 ms, P < .05). AF burden ≥10% was specifically associated with decline in strain and with P-wave prolongation. Conversely, group 2 manifest improvement in total LA strain (21.3% ± 1.7% to 28.6% ± 1.7%, P <.05) and reductions in Pmax (136 ± 4 ms to 119 ± 4 ms, P < .05) and Pdis (47 ± 3 ms to 32 ± 3 ms, P < .05). Change was not significant in group 3. LA mean voltage (r = 0.71, P = .0005), percent low voltage electrograms (r = –0.59, P = .006), percent complex electrograms (r = –0.68, P = .0009), and LA activation time (r = –0.69, P = .001) correlated with total strain as a measure of LA reservoir function.

My own AF burden 1 hour in 32 months. 1/(32x30.4x24) = 0.00004 or 0.004%.

Right, authors noted 10% burden as important in their data set. There were 18 patients in the watchful waiting cohort so I would treat the 10% burden number as something that needs further refinement. Another issue is the way AF burden is currently classfied - from 2014 classification paper by Mass General "We sought to develop and validate a patient-generated score and classification scheme for AF-related symptom severity and burden. Atrial Fibrillation Symptom and Burden, a simple 2-part questionnaire, was designed to assess (1) AF symptom severity using 8 questions to determine how symptoms affect daily life and (2) AF burden using 6 questions to measure AF frequency, duration, and health-care utilization." Not very quantitative or necessarily relatable to % burden as measured by holter. All the patients in the study cohort were classified as paroxysmal and I wonder if HRS needs to develop a more quantitative classification based on burden, whether symptomatic or not.

A 10% AF burden is 73 hours a month? correct? that's a lot of Afib.

Colin,

You are correct. My first 4 months of know afib, my burden was 57% - that included a 2 1/2 month episode which was 100% of the time. Fortunately things have been much better since...

George