I'm getting a slump with information, since we have a device clinic and we're getting information about the presence of atrial fibrillation in patients who have devices, pacemakers, defibrillators. So, I know we're not supposed to, but I'll ask one question. What do we do with patients who come to our office reporting, I have atrial fibrillation because my Apple Watch stole me and it's at 4% or 3% or 5%? I'd like to ask Christy Coleman, who's been very tech-savvy about what does this 3% or 4% on an Apple Watch really mean for us, and whether we should actually go and treat them or something like that. Thank you, Servo. So, I think there's this misconception that I think a lot of us have believed that, and patients as well, that they're walking around with a continuous EKG on their wrist. I think whenever they're wearing it, it's going to tell them whether they're an AFib. It's important to remember the AF notification is actually a regular pulse detection. And you have to remember how the Apple Watch samples for a regular pulse. So it's every two hours, it takes one minute of data. Now if the patient's active and they're walking around during that, you know, two-hour period, it's just going to skip it and go to the next. And you need five irregular tachograms or intervals over the course of 48 hours to get that notification. So it's not really representing AFib. There's no EKG. It's representing a regular pulse detection. The Apple Watch only detects AFib, not other atrial tachorythmia. So it's important to remember to tell the patient if they're seeing that, to go ahead if they haven't. Most of the newer, Apple 4 and newer, have an EKG feature, and to tell them to prompt them to actually take an EKG so we can see what's going on. So 3% and 4% or whatever percent the Apple Watch is showing, it doesn't have really any clinical evidence that this is a true burden of atrial fibrillation and requires validation with another measure. Okay. If I can please move to my talk, talking about ablation for atrial fibrillation. Starting with the case, 49-year-old active female, two kids, goes to the gym every day, two recent admissions for atrial fibrillation, spontaneously converted and has no other medical history. You saw here at the office, her heart rate is 53, her blood pressure is good, her BMI is normal. She's complaining of increasing absence of palpitations. In the last admission, in the ER, they put her on PixiBump and Metoprol, similar to the initial question we had before. And everything is normal, her TSH is normal, BNP is normal, echo is normal, and the monitor shows 10% atrial fibrillation. So which of these, and actually I'm going to ask you two if you can participate, which of these, based on your current practice, would be the most appropriate step? Would you continue the medications that she's on, anticoagulation and beta-blockers, discontinue Metoprol, she's bradycardic after all, and a PixiBump, her CHA2DS2-VASc is one, refer for catheter ablation, start her on flecainide or prescribe flecainide as needed, a spill in the pocket. If we can have some participation here. Okay, so, oops, let's go back. Oh, do we have the results? Oh, I clicked too fast, that's okay. So, there's no right or wrong answer, but there is a big change in the guidelines based on clinical data that has been accumulated over the last 10 years that I think it's important to talk about. And the major thing that has changed in 2023 guidelines is their role for atrial fibrillation ablation for treatment of paroxysmal atrial fibrillation. Many of you might say, well, I do refer all my, most of my patients who have paroxysmal atrial fibrillation for an ablation. This is what we do at Northwell, it's a large health system of 37,000 admissions in men and 30,000 in women, about 6.5% of women and 10% are referred for ablation. These are patients with paroxysmal atrial fibrillation, symptomatic, who actually got an ablation. And we think this is local, this is in par with all the other studies and it's par with European studies. Denmark, the whole country of Denmark, everybody who has diagnosed with atrial fibrillation gets in the registry and the numbers are similar, 7% of men actually do have an ablation and 4% of women have an ablation with paroxysmal atrial fibrillation. Why is that? There is a belief that it might not work as well as we thought it would. And it is true that randomized clinical trials that were recently published have shown an efficacy of about 65%, 65% in one year efficacy after ablation of atrial fibrillation. These were done in the era where patient had to fail an enterithmic and then proceed with the ablation. We can argue that they were a little later in the progression of their disease. And then came PFA, and PFA with multiple catheters, first with paroxysmal ablation, 66% similar efficacy. The first randomized clinical trial to compare the old technology with PFA, about 71% efficacy, non-inferiority of the PFA, but did not do any better. And another trial, again, about 70% efficacy. So the efficacy, the success rate after an ablation of atrial fibrillation with current technology hasn't really changed. What has really changed is the safety profile. Many of us, many of the patients were concerned about the complications, the potential complications related to ablation using thermal energy. About 10% would be pericarditis, readmissions, effusion, tamponades, and the most dreadful of all, esophageal fistula. This rate of complications has gone down to 1% to 2%. So we went from 10% on thermal ablation, the type of ablation we used to do three years ago, to 2% currently. In addition, the procedure is much shorter. So this is kind of me for you who are not exposed to the lab and you haven't really seen how the ablation was used to happen. This is me trying to burn around the pulmonary veins to create pulmonary vein isolations. This is probably 10 times the speed. I'm not going as fast, but it took a long time. It took a long time, a lot of radiofrequency lesions to achieve this result. This is what the current technology is offering us. Larger tools that oppose against the vein. One application, a few seconds, there is a field. Pulse field ablation is a field of electricity that causes apoptosis, causes the things we wanted to do. And because the intensity of the electrical field is specific to the myocytes, there's no collateral damage. So we're not concerned about fronting nerve policy. We're not concerned about esophageal injury. We're not concerned about esophagitis. So that made the current guidelines. I love that the current guidelines treat atrial fibrillation similarly to how they treat heart failure. It's a progression from presence of risk factors to develop atrial fibrillation to actually presence of structural or electrical findings that predispose to AFib to clinical AFib. And paroxysmal atrial fibrillation is the beginning of the progression, and we know that the intervention, and the intervention is in the form of ablation, could reverse that progression back to stage 2 and lifestyle modification back to stage 1. So it's a continuous progression of the disease. If left alone, atrial fibrillation is a progressive disease going to permanent AFib. For those reasons, the current guidelines of 2023 change the indication for catheter ablation to class 1. Of note, there is no class 1 in any of the antiarrhythmics for treatment of paroxysmal atrial fibrillation. So if I were to switch gears a little bit in the interest of time for case 2, a little different patient, 71 at this time, with hypertension, non-obstructive coronary disease, and mildly depressed ejection fraction, who presents for persistent atrial fibrillation. This is a gentleman who is in normal intensive, a little bit overweight, and again, AFib was diagnosed incidentally in his routine visit. He was started on Apixaban, Metoprolol, and Tresto, because his ejection fraction is low. This is a real case. This is his electrocardiogram with atrial fibrillation with mild rapid response, just above 100 beats per minute. His BNP is a little high, despite the medications that he's taking. His ZF is low. His LSI is good. His Holter monitor shows persistent atrial fibrillation 100%, with an average heart rate of 93. So we have basically rate-controlled persistent atrial fibrillation in a setting of coronary myopathy. Some considerations. Again, I'm an electrophysiologist, so I'm not going to have you answer this, because you know what I have in mind, but ablation is one option. Many of us would reach for amiodarone, as we think it's really the most effective treatment for persistent atrial fibrillation. Maybe we can do some more rate control, or just do cardioversion, or do cardioversion after amiodarone, and again, I'm not going to, because you know, my specialty kind of reveals what I have in mind. So how good is ablation of persistent atrial fibrillation? The truth of the matter is the success is, again, modest. We're talking about 60%. And ablation of atrial fibrillation for persistent is a little different than paroxysmal. We have a target for paroxysmal. We call it pulmonary vein isolation. With persistent atrial fibrillation, we want to do something in addition, and we've tried giving alcohol to the veins, creating lines, doing a lot of things, going to the epicardium, calling the surgeons. The truth of the matter is we don't have a clear strategy for treating persistent atrial fibrillation. Whatever we've done, the success is about 60%. Again, this is one procedure, one procedure outcome. But also, how about amiodarone? Amiodarone has been measured, even in the persistent atrial fibrillation, against the catheter ablation. Yes, success for ablation is 60%. Success of amiodarone is below 40%. Success of not doing anything is 0%. And why do we really have to get those patients to sinus rhythm? Because this is the only category of patients that we've shown a survival benefit. Patients with persistent atrial fibrillation and depressed ejection fraction after ablation do receive survival benefit that has not been shown in any other patient population so far. And how does PFA play a role in this? We don't have that many trials. The only single trial we had on this was on a specific catheter that's called spherodynamic biometronic, and there is a signal of maybe improved success with 73.8% over 65% for treatment of persistent atrial fibrillation. So this is, I think, a significant take-home point. We used to say that patients with heart failure, they are sicker patients, so their perioperative risk could be higher, could be higher. The opposite is supported by the evidence that this is the only group of patients who do see benefits, survival benefits. And therefore, 2023 guidelines is recommended as a class 1 indication for catheter ablation for persistent atrial fibrillation. Okay, thank you very, very much.

Apple Watch

AFib notifications

catheter ablation

treatment guidelines

heart failure