Big news in AF ablation from HRS 2016

Big news in AF ablation from HRS 2016 [www.drjohnm.org]

By EP Dr. John Mandrola M.D.

May 16, 2016 By Dr John. Filed Under: AF ablation, Atrial fibrillation, Doctoring

I have recently returned from the 2016 Heart Rhythm Society Sessions in San Francisco.

IMG_2201 I wrote three articles for Medscape. I also did two podcasts from HRS. I will link these below. You need to sign up for Medscape (free) to read the essays and listen to the podcast.

In the first article, I discussed the good and bad of AF ablation. The good being the increase in quality of life seen in about two-thirds of patients who have ablation. The bad being a study from a Japanese registry which found 1 in 3 patients sustained post-procedural “sub-clinical cerebral ischemic” lesions on brain MRI scans. To translate, that means the researchers found small areas of damage in the brain–likely from debris going north from the heart to the brain during the procedure.

Finding post-procedural ‘white spots’ are not new. What’s new about this study was the very high frequency. There are critics and downplayers of these concerns. They say…no worries, if you give enough anticoagulant drugs and manage the sheaths properly, you can avoid the problem. The non-worriers also make the point that these lesions go away over time. Maybe so. But the Japanese study I cited was larger than previous trials–and they did the procedure in the normal way.

The title of the article is The Parallax of AF Ablation on Display at HRS. History may prove me wrong, but I think being more selective in choosing patients for AF ablation will look wise.

The second article I wrote from HRS involved a new study in ablation of ventricular tachycardia. Since it’s not an AF study, I won’t say much about it here, except to list the title of my essay: The VANISH Trial Should Not Vanquish Good Decision Making. The Vanish trial, however, is an example of clinical science done well. It was a Canadian-run trial.

My third article from HRS revealed chinks in the armor of two stars of modern-day EP. Contact-force sensing catheters for ablation of AF are popular. Most operators like them (I don’t) because they tell you the pressure at the tip–which is supposed to allow for better quality burns. Up until HRS, CF catheters had not been tested in a rigorous head-to-head comparison; they had hype and eminent professors promoting them. Well, when the evidence came in, the results were negative. Use of contact force did not result in better safety or efficacy.

Another technology studied formally at HRS was FIRM ablation. FIRM stands for Focal Impulse and Rotor Modulation. Early studies with a proprietary rotor mapping machine (Topera–now recently acquired by Abbott) showed promising results. But these were not randomized comparisons. At HRS, the group of Dr. Andrea Natale did a proper trial–and FIRM flopped.

The most interesting AF ablation trial came from a group in Liverpool UK. This group studied the strategy of taking all patients who were ablated for PAF back for a second procedure, regardless of symptoms. That’s right–even those without any AF went back. The research team found 2/3 of patients had gaps in pulmonary vein conduction, and re-ablation delivered better one-year success rates. The controversial PRESSURE study endured heavy critique, but I think we learned a lot from it.

My third essay was titled: AF Ablation at HRS: Two Stars Fade and One Shines

Podcasts: As some of you know, I do a weekly podcast in which I offer 7-12 minute commentary on the week’s top stories in Cardiology. You can find these at medscape.com/twic.

JMM

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Related posts:

AF Ablation Update – 2016
In AF ablation, ask tough questions about left atrial appendage isolation
New post up over at Trials and Fibrillations–Exciting news in AF ablation
AF ablation news: Don’t get too excited by press releases



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Edited 1 time(s). Last edit at 05/17/2016 03:28AM by Moerk.

Yes Moerk, the creation of SCI (silent cerebral ischemia) is indeed a very important issue. But is is not at all 'Big news' as noted in the title above, and has been one of the biggest focus of current AFIB research increasingly so over the last 5 to 6 years. I've written 4 articles in the AFIB Report myself over the last 2.5 years on this SCI issue sharing multiple large studies and updates on our now very evolved understanding of both the proximal causes and proven steps to greatly reduce SCI creation in the first place ... foremost by restoring durable NSR (normal sinus rhythm) and secondarily by using proper techniques during an AFIB ablation which when done correctly had been shown in multiple modest to larger size well-done studies to reduce SCI creation significantly.

Silent cerebral ischemia (SCI) caused by having AFIB, first and foremost, and that it can be caused to a much lessor degree by an ablation itself in which this large new study on the issue confirms to occur in around 30% of ablations, but to a far lessor degree particularly when state of the art uninterrupted anti-coagulation methods and proper transeptal puncture and sheath/catheter techniques are used during the immediate periprocedural period ... By the way, this is a known issue in nearly every other cardiovascular procedure well that results in access to the left atrium and/or arterial vascular occurs to one degree or another.

SCI is certainly an important issue and yet, our EP blogger friend Dr. John conveyed only half of the message while overlooking the most important key point of this issue that greatly alters what one otherwise without learning and understanding the relationship of AFIB and SCI creation, might then mistakenly interpret the take-home message from this research to point to an anti-ablation conclusion, and this would be a shame with ongoing AFIB being the number one source of long lasting SCI white spots.

The key facts that must be digested to properly understand the true meaning and importance of this issue are:

1. That the single biggest source of SCI is On-going unaddressed AFIB itself, be it paroxysmal and certainly with persistent and long-standing persistent AFIB, and by a Huge margin! Pause for a moment and let that fact sink in .... It is unaddressed AFIB itself in all its forms that is THE number one source responsible for the greatest increase in overall lifetime SCI Burden in the brain, period. The number one and single most important step to preventative an increase in these SCI being created is to establish durable continuous Normal Sinus Rhythm (NSR) by whatever means possible.

The second step is to confirm that your ablationist is fully aware of and uses all the best known procedural methods and practices to reduce the creation of a small number of SCI during an ablation of other left-sided procedure as discussed below which can reduce the odds of creating one to a few new tiny asymptomatic white spots on the brain that are almost often no longer visible by MRI within a few days post ablation.

2. While SCI tiny white spots are asymptomatic individually, the weight of the very strong evidence now is that when allowed to accumulate over time they are anything but asymptomatic leading directly to an increased association with early onset dementia and Alzheimer's.

3. And while the numbers of SCI that on average are generated during cardiovascular procedures including AFIB ablation are typically limited to from one to four white spots on average that almost always, but not in every single instance, vanish from view within 48 to 72 hours (decidedly not so with the accumulated burden of SCI white matter burden that is created by AFIB itself over time).

4. This is a very important issue and luckily those of us that have had ablations with EPs using already in their ablation process what has now long ago been established as the state of the art uninterrupted anticoagulation protocol, combined with using dual ( not single sheath) transeptal puncture to prevent multiple insertions and retractions of the lasso mapping catheter and ablation catheter into and out of the left atrium as a single sheath typically requires ( upping the risk of tiny air bubbles getting into the LA and possibly traveling to the brain as well as several other established procedural steps that have been shown now in multiple studies to dramatically cut the numbers of SCI created to one or two they spots that almost invariably vanish in short order.

Plus ensuring an ACT (activated clotting time) measurement of around 350secs, or slightly higher, is maintained from just before transeptal puncture until all hardware and sheaths are fully removed from the LA and groin which also 'almost' eliminates the risk of true stroke and TIA during the actual ablation itself by those who practice these wise uninterrupted AC methods.

These steps, most all of which were pioneered at Cleveland Clinic and St Davids along with several other top ablation centers like Univ of Penn, Mass General, Mayo and the German group of Deneke and Giata in Italy etc, have shown they conclusively can reduce this risk of ablation-caused SCI to an essentially relatively negligible level, especially compared to AFIB related accumulation of SCI, so just insist on going only to an EP who is fully SCI reduction aware and already practices these protocols as a feature of every ablation they do.

But the last thing you want to do is get the wrong message from this research and go out of your way to avoid an expert ablation process that includes all the known SCI minimizing practices when you are still dealing with AFIB in spite of all efforts to tame it long term via natural or drug means. And thereby likely doom yourself to battling with atrial arrhythmia the rest of your life which would very likely result in a classics case of being 'penny wise and pound foolish' and only help ensure M a far greatly likelihood of accumulating enough SCI burden over time such that it becomes very much symptomatic in the form of early onset cognitive dysfunction, dementia or even full-blown Alzheimer's.

That big picture then is to always keep your focus on reducing your AfIB burden as much as possible while doing everything in your power to restore durable life-long NSR by other means before adding in an expert ablation process.

If you can achieve this one key goal that truly lasts and remains uninterrupted by periodic bouts of arrhythmia via the various life-style risk factor reducing and nutritional electrolyte repletion protocols we urge all afibbers to adopt as life-long good health habits to the degree that your AFIB and overall health dictate is appropriate for you, then it goes without saying that is the holy grail best case outcome any of us can achieve.

But the next best course and outcome which is a close second, and significantly more likely to be the path most of us will have to follow to achieve real long-term freedom from AFIB, as found in our long collective forum and website experience, it for the majority of afibbers to combine the best of both worlds including all the above RFM and electrolyte repletion steps along with an expert ablation process when the RFM proves insufficient to sustain truly lasting uninterrupted NSR.

Dr. John got the story half right in his report on this latest study on SCI and ablations, but overlooked the most important reality that it is ongoing untreated AFIB itself that results in the greatest SCI burden and greatest risk for dementia by a truly huge margin.

In addition, the SCI during ablation issue has become a major research topic the last 5 years and real strides have been made, and will continue to be made toward the goal of refining our understanding and protocols to totally eliminate the creation of SCI during AFIB and most other cardiac procedures open to the arterial blood flow in the heart as well.

An ancient 'lessons of life' Indian Hindu proverb is perfectly suited here: 'it often takes a small thorn to remove a much larger more dangerous thorn and then both can be discarded'.

Shannon
PS the portion of Dr John's review of another study that Moerk posted above is one in which doing two PVI ablations back to back empirically in all paroxysmal patients in this proved to give a bit better 12 to 18 month success rate than just bringing people back in for the follow up ablation only after and only if they became symptomatic. In light of the high level of PV reconnections still experienced by a large majority of EPs out there combined with the greater the effect improving establishing effective transmural results and achieve a more durable full PVI with a follow up ablation.

In this study, the structure is to bring everyone back in after two months post index ablation for a full repeat PVI that may make sense via several mechanisms that I don't have time to spell out in detail here as I'm buried in the next AFIB Report and have to leave early Friday morning for 7 nights to my old home for 38 years of my adult life in Honolulu Hawaii to take care of a laundry list of errands and appointments now.

When I have the time after I get the newsletter out, I'll go into more details and revisit the take home message from this story... But rest assured, when you go to a center that understands how to significantly reduce PV reconnection rates from the first ablation onward and keeps reconnections during or following an index ablation well below 10%, which is what St Davids as a center averages and where Dr Natale's reconnection rates are in the low single digits between 3% to 5% ... and when your EP is well versed in posterior wall Isolation as well and addressing other non-PV triggers during an index ablation, it then makes all the sense in the world to go for a follow up which is really a targeted touch up, only when and if, the afibbers starts to trigger and have episodes again either symptomatic or asymptomatic.

This approach followed by the big centers makes much more sense rather than have everyone come back in after two months following an index ablation to repeat the entire PVI and nothing else. When learning how to consistently reduce reconnection rates and how to properly and consistently achieve durable posterior wall isolation, that is the better overall goal and target young or less experienced EPs should aim for. Start with getting better the first time around. And BTW a repeat PVI will not infrequently lead to partial or complete posterior wall isolation, even if inadvertently.

Shannon



Edited 6 time(s). Last edit at 05/18/2016 07:35PM by Shannon.

-- The title is Dr. Mandrola's, not mine.

-- Quoting Dr. Mandrola's text:

In the first article, I discussed the good and bad of AF ablation. The good being the increase in quality of life seen in about two-thirds of patients who have ablation. The bad being a study from a Japanese registry which found 1 in 3 patients sustained post-procedural “sub-clinical cerebral ischemic” lesions on brain MRI scans. To translate, that means the researchers found small areas of damage in the brain–likely from debris going north from the heart to the brain during the procedure.

Finding post-procedural ‘white spots’ are not new. What’s new about this study was the very high frequency. There are critics and downplayers of these concerns. They say…no worries, if you give enough anticoagulant drugs and manage the sheaths properly, you can avoid the problem. The non-worriers also make the point that these lesions go away over time. Maybe so. But the Japanese study I cited was larger than previous trials–and they did the procedure in the normal way.

Mork

Edit by Shannon)
In the quote of Dr John in the above paragraph he states that what was bothered him about this study was the "very high frequency " of ablation related SCI found (at around 33% of cases or 1 in 3) Actually, the range of occurance by percentage in the large array of SCI studies I've read and reported on in The AFIB Report the last few years ranges from around 14% on the lower end to the 60ish% range and one group I recall counted up to 80% very tiny SCI after ablation, but this wide divergence was due to a number of variable factors that greatly influenced what was counted as an SCI or not. This included periprocedural anticoagulation regimes and other periprocedural equipment management tools used, type of procedural changes etc etc.

A major variance that greatly impacts the SCI number count post ablation is the type and method of MRI set up to detect and report actual SCI. The large studies and meta-analysis studies done by world renowned Cardiac MRI experts Dr Thomas Deneke et al, Dr. Gaita et all and Natale's group as well all urge adopting a consistent and common MRI standard be used for detecting and labeling SCI lesions such as understanding the variable of using DW-MRI (DIffusion-weighted MRI) for acute SCI detection and Flair-weighted MRI (Fluid-attenuated inversion recovery MRI) used for longer-term SCI to define a more lasting lesion.

Approaches, patient class differences, and other factors also can impact numbers counts ... This latest large study out of Japan that Dr Mandrola references above reported at HRS found around 33% SCI frequency with the process and patient groups used, which is actually not overly frequent in comparison to the overall average from all past studies.

Nevertheless, we should adopt a zero SCI tolerance to our approaches and do everything in our power to acheive that goal in all cardiac ablations as well as other cardiac procedure like CABG, mitral/aortic valve change or transplants etc. Effort should be made and continues to be made to understand all influences toward controllable SCI creation and some of the most experienced groups adopting all of the known factors that reduce Thromboembolism (TE) in ablation have also reported dramatic reductions in overall SCI lesions that appear on MRI when all of these already best known practices are adopted.

That certainly doesn't mean it's a non-issue that merits no effort to address. But rather it suggests that theoretical risk from ablation-sourced SCI can be proportionally reduced by existing methods we well as current understanding and that in any event we have no current evidence that the degree of SCI actually created by ablation itself actually leads to long term cognitive decline or dementia at all , we don't know for sure that it has any long term impact on our brains or health at all, but is wise to assume it might and plan accordingly while doing the research to determine if there is any actual harm from such modest number of tiny white spot SCI created during an AFIB ablation.

On the otherhand, we do have extremely strong evidence that SCI caused by poorly controlled AFIB is very strongly associated with early onset dementia and Alzheimer's long term, and so If it turns out a given patients best odds of long term reduction of AFIB burden requires an expert ablation process, then by all means and from all we know now, even the minor theoretical risk from the very limited levels of SCI that are reasonable to project from even several ablations would pale in comparison to the much stronger evidence (plus common sense) one would expect from long term arrhythmia generated and accumulated SCI burden.

Acquiescing and giving in to a life-long battle with AFIB out of the mistaken idea that this might somehow eliminate or reduce your overall risk for early onset dementia or Alzheimer's caused by such relatively few tiny white spots ... the lions share of which will likely disappear from view on MRI not long after creation ... sounds like a very unwise and foolish gamble if you ask me.

Shannon



Edited 9 time(s). Last edit at 05/18/2016 07:26PM by Shannon.

We are talking only about Left atrium ablations.......correct??

Correct Tim, left atrium -> left ventricle -> aorta -> brain

Debris from working in the right atrium would wind up in the lungs.

Question for Shannon, I noticed that one of the younger EPs in Natale's Austin group gave webcast presentations of their best practices for cryo balloon ablation. Do you have any idea of what portion of their AF procedures are being done with cryo and the type of patients they find suitable? What do they do on redo's with such patients?

Researcher, Cryos are only done by a couple of EPs at St David's in their ongoing research into all promising modalities and techniques, when the person is a good candidate ( meaning typical straight forward paroxysmal case with high odds of not having much extended spread of triggers sources..and when they review the fact with the patient that this is part of a research program and they agree to participate.. They are mainly targeting the PVs alone with Cryo. and also when working with SVT around the AV node of children in particular, researcher to avoid ablating inadvertently the AV node while targeting the SVT zone that is very close to the AV node especially in a childs small heart. Using Cryo there allows the EP to ablate teh area and then test ffor any delay in the AV node while the Cryo stunning can still be reversed and the target moved slightly to avoid making a child becoming pacemaker dependent for life which would not be good at all for such a reason ...

And this EPs use a combination of Cryo for the PVI Portion doing several overlapping balloon lesions, and then exchange the Cryo catheter for an RF catheter for any ablation of discovered non-PV triggers or posterior wall work they find necessary in the patient, even when up front they may have expected only a straight forward PVI-alone being needed. They also use RF for any follow-up ablation typically. Though some may use the Cryo too for reisolation just to PVs in such a redo and switch to RF for the rest of any such touch up.

Shannon



Edited 1 time(s). Last edit at 05/17/2016 08:17PM by Shannon.

Yes Moerk, I realize this was Dr Mandrola's article and lead in you quoted above and I corrected one word in my reply above to clarify that.

What Dr Mandrola fails to even point out in his review that implies that avoiding an ablation (when all other methods have failed to deliver a durable lasting unbroken life of NSR), might still be his preference, is that he does not state or even seem to recognize the fact that ongoing AFIB itself is the prime source and cause of ongoing SCI accumulation in the brain. That fact is not in any way in dispute in this field from all the accumulated studies on SCI and it's association with AFIB that clearly underscore that essential message.

Least people run off half cocked and start throwing the baby out with the bathwater leading directly to the very worse outcome long term they presumably are trying to avoid, Its very important to state that fact and context when discussing this issue, otherwise an afibber can get the very wrong impression of thier relative risks here..

I have zero problem with his article other than that frustrating oversight, which I can only imagine is due to him not being aware of this fact, Were he aware of it and still did not underscore that AFIB is the prime ongoing source or SCI and ongoing active AFIB has been strongly linked to early onset dementia and alzheimers.. and not so with ablations themselves to date, would tend to make one think he was trying to promote an agenda here and scare people away from an ablation when not a single fact from what we know would, on balance, support such a conclusion. But I seriously doubt that is what Dr John's intention was here and no doubt he was just responding the the news of this article without having digested the overriding context of degree of problem SCI from ablation versus SCI accumulating for years from AFIB itself.

Again, SCI is a real issue regardless of its source, and muchy work has been done and is coninuing to be done to reduce the relatively small footprint of SCI from even the most lax ablation procedures compared to what can happen from eyars of untreated AFIB.

AFIB brings much more of a long-term problem when SCI is allowed to accumulate indefinitely. So far, there is no real evidence at all of any actual lasting cognitive impairment or neurological deficient from the vastly smaller number and largely transient asymptomatic SCI lesions typically seen from AFIB ablations. In comparison to the type of white matter SCI that accumulated over years of AFIB, there is no comparison and the potential risk from al lthat we know today is far greater not getign an ablation, ( again when the magnesium 'cure' hasnt worked out in ones favor nor any other means ot trying to restore NSR naturally or even with drugs long term.

The big guns in this SCI research from the beginning like Thomas Deneke from Germany and Giata from Italy as well as Natale in Austin whose large center has been conducting in-depth SCI imaging on a large number of his ablation patients with De and Flare weighted MRIs for several years now. Collectively all these top SCI research centers (Deneke and Giata are top cardiac MRI specialists as well) have shown a dramatic reduction in creation of ablation related SCI when ALL the best practices are used ... not just a few of them as noted too in this latest article that Dr Mandrola did not spell out in detail ( read the full article when its published shortly)

We are fortune indeed that this issue has gotten so much attention over the last half decade and so much has been learned. Nothing really new was learned from this latest study . It was a large one and it reinforces the importance of this issue, but so was the last Deneke/Giata study and Natale has contributed a lot to this evolving issue and in how to practically minimize the impact of ablation related SCI, so it was not a news flash by any means and I realize Mork that is wasn't you framing it that way in the headlines.

Alas, this topic has diverted too much of my time this morning as it is, and I simply don't have the time right now to explain every nuance of this issue to you as I noted above. Let's leave it for now until I get finished with this issue of the newsletter that is my main priority at the moment and looks certain now to occupy a good deal of my 6 nights and 7 short and busy days of errands in Hawaii starting this weekend as well (so much for any beach time :-/, and then I can revisit any other question that may not be clear at another time.

Dr. John at the end of his report acknowledged that his gut feel might be wrong on this and what he calls "the not worried" researchers might be right. But then he says "this was a large study and the author did ablations 'normally'" without explaining what the details of the study really were (I heard the full presentation last week and it basically supports what we already know). But I didn't get the impression too that Dr Mandrola has yet read most of the other excellent research in this area so far as well, due to his not even mentioning the very strong AFIB and SCI connection, I can only surmise from his responses in his article that he has not done so and that is fine as there is way to much in this field for any of us to keep up with overall. I jsut wish he had digested that key part as it would no doubt have informed how he presented these important confirmatory findings on SCI in the context of they main origin being poorly controlled AFIB itself.

Shannon



Edited 1 time(s). Last edit at 05/17/2016 08:11PM by Shannon.

Don't look at me, I'm just a reporter. , , though glad to see a discussion (argument?).

Moerk Wrote:
-------------------------------------------------------
> Don't look at me, I'm just a reporter. , , though
> glad to see a discussion (argument?).


Hi Moerk, no this was not an argument with Dr John's report at all, only trying to clarify the key important elements around this issue that I happen to be very familiar with for possible decision making and gaining a more complete perspective on the important SCI issue.

Cheers!
Shannon

Another way around this issue is to opt for one of the Ablation techniques that burn the outside of the Heart instead of from the inside. Traditional Ablations such as done by Natale, are done Endocardially (inside). There are various other techniques out there the do the Ablation Epicardially (outside).

[arrhythmia.ucla.edu]
[wolfminimaze.com]
[www.macts.com]
[stanfordhealthcare.org]



Edited 1 time(s). Last edit at 05/19/2016 02:03AM by The Anti-Fib.

These exterior techniques also carry more overall morbidity Anti-AFIB. Also in large number of cases mini-maze AFIB ablation also require at least one endocardial ablation to address post maze flutter/AT.

This SCI creation can truly be minimized with proper protocol. And we have no indication at all so far that there is any cognitive impact from
the very limited numbers and transient nature of most SCI from ablation... This is not true with accumulated SCI accumulated and built up over time from on-going
AFIB caused likely by different mechanism like oxygen debt to brain over time as well as endothelial dysfunction long term from AFIB.

Read 2015 study by the German center led by Thomas Deneke that is the most active researcher of SCI from ablations and from AFIB itself having published a good number of peer reviewed in depth studies on SCI the past 5 years. He is both an EP and respected MRI expert.

Read this one of their latest study on SCI : "Silent Cerebral events as a result of left atrial catheter ablation do not cause neuropsychological sequels a - a MRI-controlled Multicenter study" April 2015 a Journal of Cardiovascular Electrophysiology (2015) 43:217-226. .. DOI 10.1007/s10840-015-0004-6

I'm sure this study will help out ablation cause SCI vs Long term cumulative SCI from poorly treated repeated or persistent AFIB very clear.
Plenty of evidence of cognitive dysfunction and dementia from AFIB ... Zero evidence of same via the relatively very small
Amount and tiny size of SCI during a ablation.

Conclusion summary from study:

'In this study, we demonstrate the safety of left atrial catheter ablation as it applies to neuropsychological performance. Although SCE (same as SCI) were found in half of the patients, there appears to be no clinical relevance related to post-ablation SCEs for the individual patient. Even an ablation technique provoking higher incidence of SCE (like the original multi electrode phased RF ablation catheter called PVAC by Medtronics) dos not influence neuropsychological capabilities compared to an ablation method with less SCE.'

That a the first very solidly done study looking directly at the impact of ablation related SCI directly .

Everything should still be done to minimize creation of SCI but painting the projected impact of ablation SCI to be something far higher than any evidence suggests can encorage people to either avoid an ablation at all cost while their brains continue to build up exponentially larger volume of SCI burden, and Chou s a maze over a top level catheter ablation process whe you don't have other reasons too why maze might be preferred in your case, but is only fro
Trying to avoid possible one or two tiny asymptomatic white spot SCIs is not a great trade off in my view.

Odds are good with these maze patients of stil needing a follow up endocardial ablation from left atypical flutter caused by the maze and that flutter cannot be reached epicardially, so now you add the added major recovery process of maze with incresed possibility of complications and still are likely to have to get a CA in any event or stay in persistent flutter for life.

Cheers!
Shannon



Edited 1 time(s). Last edit at 07/04/2016 03:43PM by Shannon.

Shannon, for AVNRT and where precision is needed, EPs probably use something like the "Freezor" catheter and not a balloon. The balloons are too imprecise and the risk for heart block is high. Regarding cryo balloons, thanks for the details. The following excerpt from current issue of EP Lab digest out of Stamford, CT tells the story for many community hospitals that offer AF ablation services, cryo has really taken over and I am sure we will get increasing inquiries about cryo balloons here.

"Approximately what percentage of ablation procedures are done with cryo versus radiofrequency?
For FY14-15, we did 20-25% cryoablations vs 75-80% radiofrequency ablations. In FY16 to date, we have completed 68% cryoablations vs 32% radiofrequency ablations."

Link below describes Freezor catheter. (non-balloon)
[www.medtronic.com]

Yes absolutely, researcher, they use the focal point source Cyro catheter when treating SVT, not the balloon which simply would not work for avoiding an AV Node ablation. I should have clarified that distinction between a Cryo balloon catheter for a PVI and a Cryo focal catheter for focal sources outside the PVs. In most cases, unlike the AVRNT SVT isue with kids, RF focal catheters are the way to go and most EPs used RF for those. For those few of us researching this stuff all the time, somethings get taken for granted as obvious that are not at all.

Thanks for letting out readers know the distinction researcher.

Shannon

MRI guided ablations is being tested in Germany by Gerhard Hindricks, one of the elites in the world. This will probably increase understanding in the field if not improve results in a few years.

[imricor.com]

Shannon:

I was just adding to the conversation, I realize that there are drawbacks to the procedures, and that this site does not advocate them.

As for the Mini-Maze, I remember 7 years ago, when I first started researching AFIB, I heard about the Wolf Mini-Maze and a 99% success rate for paroximal AFIB. My Doctor immediately discounted it for me, because I was Persistent AF at the time.

Hi Anti AFIB ,

It's good you mentioned it, the mini maze is a viable approach for sure, and for some folks can be the way to go, usually the very morbidly obese with LSPAF and with very large LA. It's hard to visualize well with endocatheters through a lot of fat.

But it is a good deal more invasive with a lot rougher recovery than an expert endo catheter Ablation. Plus it is just as prone to requiring post maze flutter ablation by endocardial means so it's not really a great option for avoiding the very limited degree of ablation caused SCI which from all evidence to date does not have either acute nor long term cognitive impact. Unlike the larger aras of white spots created over time by ongoing AFIB that very strongly indicate a causal relationship with early onset dementia.

Thanks too researcher for the Imricor Vision-MR link.
It's still early to know if it will pan out or not and offer real added benefit from reports at HRS.. It may offer some good uses but like all brand new tech in this field and as the OASIS RCT trial on FIRM mapping and ablation has reminded us, with brand new tech in this filed we really need to patiently await a series of very solidly structured randomized controlled trials before getting too exciting by any new approach.

But this Vision-MR system is certainly interesting and will be great if it finds a key role in front line top volume ablation centers in due time.

Am finally pulling away from gate for flight to Honolulu from Phoenix after a 40 minute delay while they had to replace the cockpit oxygen tanks and breathing system ... Well
Worth the wait to get that fixed before the 6 hour flight over the Pacific... Time to turn off IPhone.

Bon voyage!
Shannon