Presenter Panel About Procedures and General Atrial Fibrillation Questions — Video
December 30, 2013
In this video from the Get in Rhythm. Stay in Rhythm.™ Atrial Fibrillation Patient Conference, the panel members answered procedure-related and general questions from the audience.
Some of the topics included:
- How do patients and doctors decide upon the right procedure?
- What is the role of pacemakers in managing afib?
- What is the role of implantable devices, such as the Reveal monitor, after procedures?
- Why aren’t MRIs used before all ablations?
- Does afib always get worse?
- How often can ablations be repeated, and how many can you have?
- Is remodeling of the heart as serious an issue as stroke prevention?
The panel members (from left to right as you look at the video) are:
- Mellanie True Hills, Moderator
- Jay O. Franklin, MD, FACC, FHRS
- Kelley A. Hutcheson, MD
- William T. Brinkman, MD
- Kamran Rizvi, MD, FHRS
- Robert Kowal, MD, PhD, FHRS
Video watching time is approximately 32 minutes.
- Low resolution
- High resolution — YouTube
Knowing how important this information would be to those living with atrial fibrillation, we committed to do a two-camera video shoot of the entire conference—a very expensive undertaking—in hopes that you, the afib community, will be willing to help us defray those costs through a donation (instead of us charging you for these videos, which many of you said you were willing to pay for). You can make a secure tax-deductible donation here, or click on the red Donate Now button.
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Mellanie: So, let’s move on to the Q&A panel. We have with us Dr. Kowal, Dr. Rizvi, Dr. Brinkman, Dr. Hutcheson, and Dr. Franklin, and all of them do procedures. We have a couple of mic runners to help you ask your questions. So, just raise your hands as you did before. I’d like to kick this Q&A off with a question to all of the panel members. We’ve gone through about an hour’s worth of procedures that we could spend days talking about. When a patient is in front of their doctor, what does the patient need to know? What does the doctor need to know in order to make the decision as to what is the right procedure for the patient? Let me start with you, Dr. Kowal.
Dr. Kowal: There’s another three days of…
Dr. Kowal: I think it comes down to trying to understand what the long-term outcome will be from anything we do. Then you have to kind of fall back to some of the simple questions: “How old are you? How long have you had atrial fibrillation? What is your pattern of having atrial fibrillation? What other problems do you have — high blood pressure, diabetes, kidney problems?” You end up creating this kind of menu of issues. If someone has very few problems, and the afib is relatively new, we’re going to go simple — cryoablation, or a drug, or something like that. If we start analyzing further, the afib’s been around for several years, and there is a concern that there’s coronary artery disease or a valve problem, and then we look at the left atrium, and it’s quite enlarged, I’m not going to do anything of great benefit. Now, we’re calling Dr. Brinkman and Dr. Hutcheson. I totally agree with the kind of team concept and the idea that each one of you presents a different set of issues. On the one hand, it’s very confusing. There are all these approaches. On the other hand, it’s great there are all these approaches, and so, we can treat people differently as it fits them.
Mellanie: Great. Dr. Rizvi?
Dr. Rizvi: I agree with that. I think you have to look and say, “Do I have a primary electrical problem, or do I have other things, and afib is number 10 on my list of problems?” Do you know what I mean? Like, how much is the afib bothering you? That should really guide everything. As far as the treatment side goes, are you the kind of person that is okay with being on two or three different medicines long-term, or are you the kind of person that is, “Doc, do whatever you got to do. I want this thing gone, and I don’t want to be on meds.” What kind of person are you? How symptomatic are you, and what is your general philosophy with regards to invasive procedures? Those things should be a major determinant together with your doctor.
Dr. Brinkman: In my opinion, I think people with paroxysmal afib, it’s pretty clear that if you need some sort of treatment like an ablation, a catheter ablation is the way to go. When you start moving into the persistent, long-term persistent, it’s an open question — it’s a research question right now. I’ve had my biases. I think surgery is very good, but it’s more invasive. I would talk to my EP doctor and say, “Are there any research protocols going on?” Then you could get access to some of the latest things. You may be helping yourself and also helping your fellow man getting involved with those studies.
Mellanie: Great. Dr. Hutcheson, do you want to add anything?
Dr. Hutcheson: I don’t have a whole lot more to add other than the point that Dr. Rizvi just made is an important one, which is having the workup originally to ensure that there’s not a structural reason that you have the afib. Occasionally, that gets missed out in the community. That is important to have that initial look, which I think you talked about, starting with an echo to make sure that everything, valves primarily, are okay.
Mellanie: Right. Okay. Dr. Franklin?
Dr. Franklin: I’m going to go back and reiterate the most important couple of pieces: “What are your symptoms? What can we do to make you feel better?” There are a fair number of patients who don’t have symptoms. If you really aren’t symptomatic, then putting you through much of this stuff at all may not be appropriate because we’re unlikely to make you live longer with all the things we do. We are likely to make you feel better if you feel bad, and we’ve got great technology to achieve that. We’ll help individualize it for every patient to help you find what works best for you. It may be simple medicines, it may be complicated medicines, it may be one of the catheter ablation techniques, or it may be something that we’re looking at and is being done in an avant-garde fashion of having the electrophysiologist and the cardio thoracic surgeon in the same room, doing the best possible initial procedure for the individual patient.
Mellanie: Great. Thank you.
Dr. Brinkman: I’d just add one thing. If you were to have afib associated with coronary disease or valve disease, it might be a different situation than lone afib because there is data to show they are extending life there.
Mellanie: Right. And I’d like to tag onto that. That has become one of my pet peeves. I don’t often express my opinion, but about five years ago, I was doing a program with a hospital, and a woman stood up and said, “My mom just had her valve replaced. Her afib is worse.” We started asking if they had actually treated for her afib when they went in to replace her valve, and they had not. Why would you put someone through two separate procedures when you can fix the problem when you’re in there? One of the slides that was shown was about the whole area of doing this when you’re in there doing other things. If you’re having a procedure for a valve replacement or for a bypass — a CABG, it’s called — please ask your doctor, “Can they fix my afib while they’re in there?” Because we’re seeing that 50%, 60%, 70% of people who have those two procedures — a valve replacement or repair or a bypass — are not getting treated for their afib. That just, in my opinion, shouldn’t happen. Let’s move on.
What is the role of pacemakers in treatment of atrial fibrillation? I know this is of interest because several of you have come up to me and said, “Are you going to cover pacemakers?” Let’s talk about that both with and without AV node ablation.
Dr. Rizvi, you want to take that?
Dr. Rizvi: There are a few different potential benefits of a pacemaker. A pacemaker, in some cases, will allow us to treat the afib more aggressively. By that I mean, a lot of the medicines we use, if your heart is slow to begin with, it’s going to make it even slower. And so, in order for us to have flexibility with respect to medications, the pacemaker really helps us to where we’re not afraid of the heart going too slow. The pacemaker will establish a floor, and it will say, “Your heart will not go below 60 beats a minute.” And then on top of that, we can put on medicines to keep the afib at bay. So, in that sense, it really helps manage afib from a medical perspective. If you put that together with an AV node ablation, in my mind, I think of that as being really useful for patients that have multiple medical issues, and their heart is just going really fast from afib, and there’s nothing that we can do to control that. In that case, if you ablate the AV node, the analogy I use in the office, it’s like this light on top of us, and the light switch is the afib. If the light switch is flickering on and off, that light is going to flicker, but if I cut the wire between the switch and the light, the switch can flip all day, but guess what? The light is not going to flicker, right? When we do an AV node ablation, we’re cutting the wire that connects the atrium to the ventricle. We cut the wire, and then we have the pacemaker take over the heartbeat. That is one step beyond just putting in a pacemaker. In my mind, that is reserved for folks that have really difficult to control afib.
Mellanie: Great. Anybody want to add anything?
Dr. Franklin: I think that what he just described, the AV node ablation, has been a fantastic treatment. Really, it was our very first catheter ablation that was ever done was a technique that was developed back before I did my fellowship, back in the mid-80s, and allowed us to treat patients that we never thought we’d be able to successfully treat. We recognize now that patients can get harmed from long-term, very rapid rates, and it was a way that we could protect them from those rapid rates. A hundred beats a minute all the time, not a big deal. But if you’re 140 beats per minute for months, and months, and months on end, it can cause deterioration of pumping function. We readily recognize that and are aggressive about treating people to help protect their pump function, if we can. We’re using pacing therapy for treating poor pump function so there are components there, and the more complicated heart trouble you have, the more likely we are to consider pacing. When I sit down with a patient for the very first time with afib, I tell them right upfront that although I don’t expect a pacemaker to fix them, and we’re not going to use that as their initial treatment of their afib, a fair number of those patients are going to end up with pacing therapy. From the surgical data you saw presented, there were numbers about how many patients needed pacemakers. I don’t see that as a huge drawback. It was considered a concern early on as the surgical techniques were developed, but so many of you that have complicated issues with your afib and other heart disease, may well end up with pacing therapy no matter what we do. It’s an important thing to look at upfront, and I have to tell patients that. Patients, in general, want to think, “Well, why can’t you just put a pacemaker in and fix me?” And, unfortunately, it doesn’t usually go that way.
Mellanie: Alright. Okay. Did you have something to add? One caveat is that — and correct me if I’m wrong — once you’ve had an AV node ablation, it’s necessary to be on anticoagulants forever because of the risk of that. Has that changed?
Dr. Kowal: Well, in general. The devices will change that.
Dr. Franklin: There are patients that have AV node ablations that sometimes remain in normal rhythm so it occasionally occurs. I don’t do that very often, but there are occasional patients, depending on their risk stratification, may not need anticoagulation. It’s a good general concept that you’re going to need long-term anticoagulants there.
Mellanie: Great. One more question before we open it up for your questions about procedures, and that is what is the role of implantable devices, such as the Reveal monitors and those kinds of devices after afib procedures? Because we get asked that a lot.
Dr. Kowal: I think the long and the short of it is we don’t know. The problem, as you kind of can surmise from the struggle, is it’s hard to know what a positive result with these procedures are. It’s clear on the one hand, if you never have atrial fibrillation again, that’s great, and that’s pure success, and Mellanie, you fall into that category. I can tell you, I probably have 30 seconds of afib now and then. I’m sure I do. After these procedures, it’s hard to know, for example, we don’t know how much afib do you need to have to be at risk for stroke. How much afib do you need to have to have all these other issues that go on? It’s hard to know what to do with the information on the other end after the procedure. For example, if you’ve gone from having afib all the time to 20 minutes of afib once a year, I’d call that a success. In our trials, that’s a failure. You have to separate what we’re trying to do scientifically from what is a good outcome for patients. I think, for right now — and I’m sure because I’m on video, I’ll get attacked for this — the role of an implantable device, a separate procedure just to monitor afib continuously, is in the realm of trying to get scientific information as part of a clinical trial.
There are a few people where that may not be true. In other words, if you can’t be on a blood thinner for some reason and we have to know when you’re having afib, that may be different. I think for right now, I’m using that as part of trying to better understand how these other treatments work in the subset of people who are enrolling in trials and studies.
Mellanie: Okay, great. Thanks. Any other comments about that or should we… Okay.
Dr. Brinkman: Well, we use the Reveal monitors after our mazes, because we follow them very closely. That data we showed, you may not have been that impressed, but that’s really well-followed patients.
Dr. Franklin: But that’s from a research standpoint.
Dr. Franklin: And what happens often times in a non-research mode is that, as much as Dr. Kowal alluded to, if the patient is happy with how they are, we’re happy, and if you have a little afib, no big deal.
Dr. Kowal: So, two quick comments. One, everyone who has afib has episodes that they don’t even know about, and that’s part of the reason why stroke management has to be managed very carefully — what we call asymptomatic atrial fibrillation. Also, just because you have an implanted device recording things, and it says it’s afib, doesn’t mean it is because there’s error rates with these recording devices, too, just as there’s error rates with our perception of atrial fibrillation. Sometimes the devices lead you to believe there’s atrial fibrillation when there isn’t and when you put multiple types of devices at the same time. So, it’s not a simple solution of “Oh, I have this recording device, therefore I know everything.”
Mellanie: Great. Thank you.
Dr. Rizvi: Yeah, I would agree with that. The other thing I would say is the actual monitors are changing. They may be coming out with a new — the current monitor that we’re all talking about kind of looks like a USB flash drive or a thumb drive, and it goes just underneath your skin. They’re coming out with new ones that you can actually inject underneath the skin in the office. Those are still in the experimental stages, but when that monitor gets injectable, I would imagine the rate of people using that would be a lot higher, as well.
Mellanie: Great. Was there anything else before we go on? Those are the questions that you asked me to ask. So, what questions do you have for our panel?
Question: Briefly about using an MRI to map, I think it was stages of afib Utah 1 through 4. Why don’t, if you’re going to have an ablation — I’m doing a cryoablation — why wouldn’t they always use an MRI to map the atrium?
Dr. Rizvi: That’s a good question. What you’re referring to is using the MRI to detect the amount of disease in the atrium. I think still in 2013, I would still classify that within the realm of investigational, but just ever so slightly moving into the mainstream. Not quite there yet. The reason why is because it takes a lot of expertise to obtain those MRI images, and then to analyze those MRI images also takes a lot of expertise. Most MRI centers, especially out in private practice, do not have that level of sophistication at this point in time. I think as the technology becomes easier to use and as more and more MRI labs know how to acquire that data, I think you will see increased adoption of that MRI data. I think at this point in time, it’s not quite made it into the mainstream, but I think it’s really on the verge of doing so.
Once you use it, you can’t really go back, as a doctor, once you start doing the MRI thing and staging the afib. Then if you don’t have it, you kind of feel like you’re blind, but I think that technology has got a little bit further to go before it truly becomes mainstream. Also, on an academic side, there’s some data that we are still waiting to see, as far as the reproducibility of the MRI data at other centers. Primarily, most of that data is coming out of Utah because we have certain expertise in Utah, but we want to make sure that it can be reproduced in the community and the same results can be obtained before widespread adoption takes place.
Mellanie: Great. This gentleman here in the blue.
Question: Could I ask all of the doctors — whoever wants to respond — our cardio physiologist told us that afib begets afib, and so that we have to interfere with the process at one point because it’s going to continue and get worse.
Mellanie: Great. Thanks. Who wants to?
Dr. Franklin: I’d say we all believe that. We all learned that. I’m not sure that it’s going to always get worse is necessarily true, but once you’ve had atrial fibrillation, the likelihood is pretty high that you’re going to have more afib. We all see incidental cases of a patient that had one episode of afib following an episode of pneumonia that they were hospitalized for, and then didn’t have another episode for 10 or 15 years. But the typical patient with atrial fibrillation is going to have more, and unless we do something to change that pattern — whether it’s a drug, whether it is ablative therapy, whether it’s a surgical approach — they’re going to keep having afib. Part of what Mellanie was appealing to the group, that as you talk to your doctors about, you have to realize that there is a difference between the group of us here sitting here and the average cardiologist and the average cardio thoracic surgeon. So, we’re all very tuned in to the arrhythmias in our patients, especially in afib. It’s based on the fact that we can actually do something more for the patient perhaps than the general cardiologist may be able to do for the patient. It’s not uncommon for you not to think about the other options for a patient. Not that you shouldn’t, but you may not think about all the other options that are available when you look at an individual patient. That’s another reason for you to be so informed.
The other thing that I thought about with afib begetting afib — we’re working to train the general cardiologist to say, “Okay, once they’ve had afib, I’ve got to do something.” The tendency among most cardiologists is to say, “God, I hope they don’t have any more afib,” and to not do anything. Whereas we all move pretty quickly to institute the next step because our attitude is if you’re on a moderate potency drug, and you’re still having atrial fibrillation, then I need to talk with you about a catheter ablative approach. Or if you have a valvular heart disease and you fail the drug, then we need to talk about fixing your valve and getting a maze procedure done at the same time. We’re moving on much more quickly in the treatment approach.
Mellanie: Okay. We have two more questions, and we need to try to get those in in about three to four minutes. This lady and then the gentleman in the blue shirt.
Participant: Mine’s a quick one. How often can a radio frequency ablation be repeated, and in your experience, what’s the maximum number of times that can take place?
Dr. Franklin: I’m not doing that one.
Dr. Kowal: Everyone’s looking at me. How often can it be repeated? It can be repeated any number of times. The question is: “Should it be repeated?” I think it depends on a couple of things. When I have a patient who sees me who’s had an ablation by me or someone else and they’re coming back, again, there are several things I ask. One is, “How long did the first one work?” If that one worked for a long time and then you’ve come back, I’m more likely to go back and look for something else because you’ve already shown that this is a therapy that can help. Whereas if you’ve had afib for a long time and multiple problems and we did this, and boy, it didn’t take very long for it to come back, no matter what, I’m less excited about putting you through that risk. Now, we’re talking surgery. Now, we’re talking something else that’s not involving ablation. So, that’s one thing. The other thing is my approach is often if one approach failed, then don’t just do the same thing over and over again. Attack it from a different approach — either a different energy, a different surgery, or a different set of tools. What else should I say? I think that’s it.
Mellanie: That’s great.
Dr. Franklin: So, it’s really not a limited number.
Dr. Kowal: No. It also depends on what you find when you go back, and this is an issue we talked about. If you go in and see that all the pulmonary veins have these gaps and are connected, then you’re going to redo that. The problem we see with our cryo cases — on the few we go back in on — the pulmonary veins are fine. So, now we have to scratch our heads and do that hunt for something else.
Dr. Franklin: That whole issue of how often do you keep redoing may well be answered by the MRI question that was raised. And standing at the back of the room earlier this morning, Dr. Kowal and Dr. Rizvi and I were all talking about together that it’s a technology that we’re not currently using, but might be something that would be very helpful. If I have a patient who sees me, having had two previous ablations by good operators at good locations, and they’re having recurrent atrial fib, then having them get an MRI, for example, and saying, “Oh my God, we’d have never been successful. There’s no reason to go back. Let’s look at another option for you like an AV junction ablation” could be very helpful if they’re a Utah Stage 4, for example. This is a constantly changing field. What we’ve talked to you about today may be vastly different 5 years from now, 10 years from now. All of us, even the youngest ones in our career, have seen attitudes and technology change dramatically in a short period of time. There’s more work being done in afib, ablative therapy, surgical, catheter-based stuff than anything else in the whole arrhythmia field at this point in time.
Dr. Kowal: One last thing I’d say is it also depends on what your rhythm is when you fail. If you have a procedure and you come back with atrial fibrillation, that’s harder to fix than if you come back with one of these atrial flutters, or what’s called atrial tachycardia, i.e. a more organized rhythm. Because the more organized rhythms that are less irregular are easier to localize to a spot or a region, as opposed to going after atrial fibrillation again. That’s important as well.
Mellanie: Okay. And we had one more question. Can I get your permission to let us go over for two or three minutes so we can get this question in? Everybody okay? Okay. Let’s do it.
Question: I know that we talked about the number one concern as being treating a stroke. I also am concerned about — and I don’t find very much research, I haven’t heard you comment on — the remodeling of the heart as a problem. I don’t know how long my ticker will last if I keep from having a stroke, I guess.
Dr. Rizvi: I’m going to take a stab at that question. That ties into some of the things we were doing in Utah. That’s a very good question and a very insightful question. We know that patients with afib have a much higher risk of congestive heart failure. We also know that patients with afib — the more afib you have, the more likely your atrium is going to be enlarged and structurally abnormal. So, I agree. I think stroke risk is number one on everyone’s list because a third of all strokes are related to afib. It’s just a major problem, and you only need one, but I definitely think treating afib for the sake of preserving a normal heart from adversely remodeling is an important thing. That’s especially true in patients with congestive heart failure. If a patient has congestive heart failure and they’re short of breath — if those patients are having afib, and you ablate them, and now you get rid of afib, a lot of times the congestive heart failure will get better, as well. I think that’s a very good question that you asked, and that’s something that is also one of our targets when we ablate patients.
Dr. Kowal: Related to that is the fact that, as we were talking about, the heart doesn’t exist on its own. It exists in concert with other organs. So, for example, afib isn’t the only thing that drives remodeling of the heart. High blood pressure leads to scarring of the left atrium that you see. Sleep apnea does. Kidney failure does. If you ignore those other things, like I was saying, we can do all we want surgically, with catheters, on the afib — it won’t make a difference if we leave those other areas unattended. When you’re talking with your physicians, one of the mistakes we see is that someone comes in with five medical problems and they’re view is, “Well, if just the afib was gone, I’d be fine.” No. The afib may be just as much a consequence of those things as a cause of your problems. It’s almost a contract: “Yes, we’ll work on the afib, but we’ve also got to work on all these other things.” It doesn’t exist on its own. That’s part of our solution.
Mellanie: Was there one last comment?
Dr. Hutcheson: Well, and when you mentioned research on that, one of the things that makes that a very difficult research question to answer is this complex relationship that has just been described here. It’s very, very difficult to take a patient that has gotten to the level of cardiac remodeling and isolate what are the primary contributors to do that. And so, that is an important question that all of us are certainly interested in and will come out over time, but there’s a lot to do to figure that out.
Mellanie: Let me ask if you would stay up here while I close for the next three or four minutes in case people have questions. Everybody okay? Okay. Let’s thank our panel for a great discussion.