Wow, that is an amazing result given the technology back then, as Shannon said. Catheter technology has come a long way since. Best wishes for another successful outcome with Dr. Natale. I am sure he would enjoy a revisit with you after all these years.by researcher - AFIBBERS FORUM
I just read the article and some of the comments from general cardiologists are appalling with regards to how their patients are being managed and in one case downright refusal to refer patients to any EPs. My opinion is that Dr. Mandrola's idea may add some useful information if it is focused on centers that do less than 25 ablations per year and represent a majority of AF ablation volume.by researcher - AFIBBERS FORUM
Shannon, the problem with cryo balloon that I was afraid of has just been elucidated in the latest issue of EP Lab digest. A spotlight inteview article regarding Banner Health in Arizona. The director of EP said in the interview that they are extending cryo balloon to persistent, long standing persistent and substrate modification. This is a predicable over stretch of the fundamental limitatioby researcher - AFIBBERS FORUM
Shannon, We are studying health plans on the exchanges as we speak. Years ago, there were big differences between HMOs and PPOs. Not anymore. In our county Kaiser HMO premiums is about the same if not higher compared to Cigna or Aetna PPO for example. We will have to look closer to see what's going on. I know from my parents experiences that Kaiser is excellent for preventative care andby researcher - AFIBBERS FORUM
Shannon, along the same thoughts, Sam Asirvatham of Mayo published recently a review of sub clincal strokes during AF ablation and long procedure time and sheath changes are big contributing factors. I think the article is in the latest "innovations in CRM". As you said the big attractiveness to EPs and centers are shortened procedure times using Cryo and subsequently being able to doby researcher - AFIBBERS FORUM
This adds longer follow up data regarding post procedure re-hospitalizations compared to when first reported Fire and Ice trial results. The reduction in burden and reduced hospitalizations is a big deal and probably why cryo is being used more often in place of RFA, for paroxysmal AF. I sitll worry about phrenic nerve injury and PV stenosis, the former being the most devastating and althoughby researcher - AFIBBERS FORUM
The most significant difference between OASIS early termination (due to futility) cohort and prior center FIRM studies is that the early termination happened in the FIRM-only arm whereas prior 10 centers study showing ~80% freedom at 12 months from AF were FIRM-followed by- PVI. Big distinction when looking at the results. I am not so sure that FIRM mapping is completely invalid as implied hereby researcher - AFIBBERS FORUM
Many have attempted injected cell therapies for heart muscle repair, all have failed so far. The latest was Celladon (http://www.fiercebiotech.com/financials/celladon-pulls-plug-on-r-d-after-a-crushing-gene-therapy-failure). The only recent drug (oral) that shown any positive impact on reduced hospitalization is from Novartis (see Entresto) Many will continue to try with cell based therapy noby researcher - AFIBBERS FORUM
Bravo - you may find the following video from Brigham and Women's informative with regards to what the EP will do during the procedure.by researcher - AFIBBERS FORUM
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.by researcher - AFIBBERS FORUM
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 ablatioby researcher - AFIBBERS FORUM
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?by researcher - AFIBBERS FORUM
The same British group has a very interesting and detailed CF review article in the current issue of Journal of AF that goes over data. CF has increased EP's understanding of sufficient tissue contact, both too much and the lack of. Between 10 grams and 20 grams, lesion size is the same. Above 30 grams, care is needed on RF power to avoid steam pops and perforation.by researcher - AFIBBERS FORUM
Peggy, Sorry. Registration is required and it is free. I have been registered several years now and they are spam free as far as I can tell.by researcher - AFIBBERS FORUM
The big discrepancy in phrenic nerve palsy complication results between "FIRE and ICE" and "STOP-AF" stoked my curiosity as both trials were sponsored by Medtronic. The former were all high volume EU centers with big representation by German referral centers and the latter is around a 60-40 mix (USA and Canada) of referral centers and community hospitals. Still the spread isby researcher - AFIBBERS FORUM
We all take calculated risk to enjoy nature. Nature was a beast this last surf season in Hawaii. Four days after the seven stitches, I caught the best wave of my life. I will probably not see waves like that again where I am in a decent enough condition to surf them. Life without any risks is not living. I lap swim daily so I won't suggest to others, including young surfers, to surf bigby researcher - AFIBBERS FORUM
I finally had to a chance to go through the article and appendix containing the trial details. When Kuck wrote about 8 countries and 16 centers, I assumed some US centers were involved. However, only high volume EU centers were involved. That explains the lower phrenic nerve palsy complications (2.7%) experienced in the trial compared to Doug Packer's review of STOP-AF trial which showedby researcher - AFIBBERS FORUM
You guys are inspirational. I had a close call this year surfing in Hawaii that required 7 stitches. My regular doctor said to me disapprovingly/jokingly that people like us keep him in business doing dangerous stuff.by researcher - AFIBBERS FORUM
Just released online on NEJM. Principal investigator was Karl Kuck of Hamburg. More details on the trial in the appendixby researcher - AFIBBERS FORUM
There are a couple of articles in the NEJM regarding the randomised trials of statins vs placebo. The numerical results differ with the opinions cited above.by researcher - AFIBBERS FORUM
Shannon, I was hoping that Dr. Young would answer with additional details regarding the specifics that were not addressed, ie monitoring method, frequency, on or off AADs. I am afraid this is the best I can expect for now. It is too bad I had to go through the author and not directly email Dr. Young. I would have been able to ask more follow ups. Kaiser has huge coverage in CA and many AF patby researcher - AFIBBERS FORUM
With regards to the first post and subsequent inquiry to Kaiser regarding details, Dr. Charles Young responded through the author of the article. From Dr. Young - "The 6 month success is what is typically published in the literature and is generally lower than the 2 year success as late recurrences do occur. Our 6 month success rate that was mentioned in the article pertains to a selectby researcher - AFIBBERS FORUM
The first time I heard about it was 2008 during an expert panel discussion about how the top guns do their ablations. The presentations/panel consist of Natale, Packer, Reddy, Pappone, Kuck (perhaps 1-2 others that weren't on the podium) and the dragging (not lingering in one spot) was discussed then as the preferred approach for generating ablation lesions. There wasn't anything formby researcher - AFIBBERS FORUM
Shannon, With regards to CF catheter ablation, below some data comparing the different modalities. If one is good at it with SF, CF does not seem to add much based on current data. (See figures 1 and 2). As Vivek Reddy said though, CF certainly makes a difference for those coming up on the learning curve and he insist on fellows using CF.by researcher - AFIBBERS FORUM
I have emailed the department there in Santa Clara and ask for clarifications regarding single procedure 90% success rate and overall success rate including more complex AF cases. I will post response if I get one. Here is what the Kaiser Santa Clara EP department sends out to ablation patients as of 2 years ago -by researcher - AFIBBERS FORUM
Many CABG patients already have AF going into CABG operations so it is not clear if the study took that into account (ones with existing AF probably got mini-maze as part of open heart procedure, standard of care) from Dr. Day's review. For patients that don't have AF going in, about half of them will get AF after CABG so the 30 out of 30 success results is significant no matter what.by researcher - AFIBBERS FORUM
I find this amazing coming from what I would consider a non top tier program. In the article, they refer to "early" AF cases so this would presumably be paroxysmal and folks that are just several weeks into persistent. Everybody is getting better at AF ablation. I don't know how big a factor the magnetic navigation system (Niobe) plays but it probably helps significantly. Thiby researcher - AFIBBERS FORUM
I missed this when this came out during the last HRS meeting. From Dr. John Day's wrap-up of 2015 EP clinic findingsby researcher - AFIBBERS FORUM
McHale, I think by now, everyone that publish about AF ablation drag the catheters along the desired lesion sets and go back to focal during the challenge tests, so Natale is not alone. I think all the elites have been doing this for years now since they share best practices. I still see animations on the web that show point by point ablations to get the concept across to patients and those neby researcher - AFIBBERS FORUM