Atrial Fibrillation (AFib) Support Group
Atrial fibrillation (AF or afib) is an abnormal heart rhythm (cardiac arrhythmia) which involves the two small, upper heart chambers (the atria). Heart beats in a normal heart begin after electricity generated in the atria by the sinoatrial node spread through the heart and cause contraction of the heart muscle and pumping of blood.
I don't think most of the following will be news to most of you.
Anyhow, I chose "ice"; going for ablation procedure on Tuesday. This is after 2X 120 mg sotalol stop working for me and after 2 cardioversions in the last 2 months.
Fire or Ice for AF Ablation? Operator Experience Counts
June 24, 2015
When it comes time to perform AF ablation, many ask the question: Should we freeze or burn? Which technique of pulmonary-vein isolation (PVI) is best?
The two most common techniques for PVI are point-to-point RF ablation and cryoballoon ablation. Heat or cold? Fire or ice? Dots or circular lines? At electrophysiology meetings, this is a hotnot coldtopic.
We debate this issue because there is currently far more eminence than evidence. Trials comparing the two strategies have been limited by small numbers of patients, nonrandomized designs, and single-center experiences. A recent meta- analysis of these small studies showed equipoise for safety and efficacy[1]. A German registry of 3775 nonrandomized consecutive patients with AF also reported comparable outcomes[2]. The FIRE AND ICE trial will fill that void; it is a large multicenter randomized clinical trial that has finished recruiting patients.
But even when FIRE AND ICE is reported, there will still be the matter of generalizing data from experienced centers to the real world.
Here, I think it best to consider this debate from a patient's viewpoint. In other words, if you were the patient, which technique would you choose?
One factor you would consider is the experience of the doctor and center. Both techniques of AF ablation require skill, but most electrophysiologists would agree that point-to-point RF ablation demands more time and procedures to master. Compared with the one-shot PV isolation with a cryoballoon, RF ablation involves intricate movements and delivery of many singular lesions to isolate the vein. Where an operator is on this experience curve may be an important factor in comparing the efficacy and safety of the procedure.
An abstract in the young investigators award presentations at Europe an Heart Rhythm Association (EHRA) EUROPACE- CARDIOSTIM 2015 sheds light on the relationship between experience and outcomes of the two PVI techniques.
Dr Rui Providencia (Clinic Pasteur of Toulouse, France) presented results of an observational study from six centers involved in the FrenchAF registry[3]. For this analysis, the research team included only centers performing more than 100 procedures per year. The characteristics of the patients were typical of those with paroxysmal AF. The CHA2DS2-VASc
score was slightly higher in the cryoablation group (1.6 vs 1.4, respectively). The primary outcomes were AF suppression and safety.
Four of the six centers fulfilled entry criteria for the study. There were differences in experience at these centers. One center did only cryo, one did mostly cryo, one did mostly RF, and the largest-volume center was evenly split. Average follow-up was 30 months.
Results
In overall safety, researchers noted no significant differences (5.9% for cryoablation vs 6.0% for RF ablation). As expected, they observed seven phrenic-nerve injuries (1.9%) with cryoablation and none with RF.
For cryoablation, the four centers performed nearly identically. Kaplan-Meier curves were superimposable, and overall rates of success varied from 78 to 81%.
For RF, the three centers varied in success rates according to procedure volume: 81.3% in the center performing more than 150 RF ablations per year, 61.5% in one performing close to 100, and 44.1% in the one performing less 70 AF RF ablations (P
Anyhow, I chose "ice"; going for ablation procedure on Tuesday. This is after 2X 120 mg sotalol stop working for me and after 2 cardioversions in the last 2 months.
Fire or Ice for AF Ablation? Operator Experience Counts
June 24, 2015
When it comes time to perform AF ablation, many ask the question: Should we freeze or burn? Which technique of pulmonary-vein isolation (PVI) is best?
The two most common techniques for PVI are point-to-point RF ablation and cryoballoon ablation. Heat or cold? Fire or ice? Dots or circular lines? At electrophysiology meetings, this is a hotnot coldtopic.
We debate this issue because there is currently far more eminence than evidence. Trials comparing the two strategies have been limited by small numbers of patients, nonrandomized designs, and single-center experiences. A recent meta- analysis of these small studies showed equipoise for safety and efficacy[1]. A German registry of 3775 nonrandomized consecutive patients with AF also reported comparable outcomes[2]. The FIRE AND ICE trial will fill that void; it is a large multicenter randomized clinical trial that has finished recruiting patients.
But even when FIRE AND ICE is reported, there will still be the matter of generalizing data from experienced centers to the real world.
Here, I think it best to consider this debate from a patient's viewpoint. In other words, if you were the patient, which technique would you choose?
One factor you would consider is the experience of the doctor and center. Both techniques of AF ablation require skill, but most electrophysiologists would agree that point-to-point RF ablation demands more time and procedures to master. Compared with the one-shot PV isolation with a cryoballoon, RF ablation involves intricate movements and delivery of many singular lesions to isolate the vein. Where an operator is on this experience curve may be an important factor in comparing the efficacy and safety of the procedure.
An abstract in the young investigators award presentations at Europe an Heart Rhythm Association (EHRA) EUROPACE- CARDIOSTIM 2015 sheds light on the relationship between experience and outcomes of the two PVI techniques.
Dr Rui Providencia (Clinic Pasteur of Toulouse, France) presented results of an observational study from six centers involved in the FrenchAF registry[3]. For this analysis, the research team included only centers performing more than 100 procedures per year. The characteristics of the patients were typical of those with paroxysmal AF. The CHA2DS2-VASc
score was slightly higher in the cryoablation group (1.6 vs 1.4, respectively). The primary outcomes were AF suppression and safety.
Four of the six centers fulfilled entry criteria for the study. There were differences in experience at these centers. One center did only cryo, one did mostly cryo, one did mostly RF, and the largest-volume center was evenly split. Average follow-up was 30 months.
Results
In overall safety, researchers noted no significant differences (5.9% for cryoablation vs 6.0% for RF ablation). As expected, they observed seven phrenic-nerve injuries (1.9%) with cryoablation and none with RF.
For cryoablation, the four centers performed nearly identically. Kaplan-Meier curves were superimposable, and overall rates of success varied from 78 to 81%.
For RF, the three centers varied in success rates according to procedure volume: 81.3% in the center performing more than 150 RF ablations per year, 61.5% in one performing close to 100, and 44.1% in the one performing less 70 AF RF ablations (P
My first ablation back in February used cryo. My second ablation (performed 6/26) was RF.
My EP told me that the catheters he used on me this time are relatively new, in that they also contain fiber optic material that allow the operator to monitor how much the catheter is being bent or deflected, which means that it's now possible to monitor the pressure used for each burn. There were several other EPs present during my procedure just observing how the new catheter is used.
Pressure (and using just the right amount of it) is so much more important than I realized from any of the reading I did on ablations - it's really not ever discussed. Knowing what I know now, that would be one of my main questions to any EP before doing an ablation - "how do you regulate the pressure used during burns?"