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Minimally Invasive Treatment Options for Atrial Fibrillation (A-Fib)

Minimally Invasive Treatment Options for Atrial Fibrillation (A-Fib)


Angie Weidinger:
Welcome to this Facebook Live event. We’re coming to you from the Barnes-Jewish
Hospital cardiac catheterization lab. I’m your host, Angie Weidinger. And this is Dr. Mitch Faddis. He is with the Washington University Barnes-Jewish
Heart and Vascular Center. And we are in a room that I would not normally
be in, unless I was having some kind of procedure done, which is really exciting for me, to
get to see all of this innovative technology that we’re surrounded by. And that’s what we’re going to get to
talk about today. Actually, to even get to come into this room,
we had to, I had to don some special gear, some special wear that’s very comfortable
I might add. But to come into this room, we had to wear
this, and we’re going to talk about this technology in a way that hopefully, many of
you will be able to understand. Where our goal is to keep it interesting and
simple, so that people like me, not in the medical profession, could understand. So, Dr. Faddis, you are an electrophysiologist,
which I had never really even heard that before. What is an electrophysiologist do? Dr. Mitchell Faddis:
Well, thanks, Angie. An electrophysiologist is a cardiologist. Angie Weidinger:
OK. Dr. Mitchell Faddis:
Who specializes in the electrical system of the heart. And as we were speaking about recently— Angie Weidinger:
Right, I wouldn’t even normally think about the heart in an electrical way. Dr. Mitchell Faddis:
Yeah, yeah, well that’s an important concept, because the heart is a pump. Most of us know that it pumps blood. But that pumping action is stimulated by a
natural pacemaker that generates an electrical signal that flows from the top to the bottom
of the heart. And in the wake of that, the mechanical action
of the heart happens. And the heart relaxes and it waits for another
electrical signal. Now the rhythm problems that I see, the electrical
problems that I see have to do with a disruption of that natural rhythm. And atrial fibrillation, which is what we’re
going to focus on today and talk about, is the most common electrical problem that people
have. And it involves— The top part of the heart that’s generally continuous. And what happens with that is, the mechanical
action of the top part of the heart is disrupted. And the bottom chamber is set in motion at
a much higher and irregular rate. So combination of those two, the lack of efficiency
of the pumping action and the increase in the rate results in symptoms. And things like shortness of breath or fatigue. Even chest pain, lightheadedness. Just an overall inability to do things, are
common symptoms for people with a-fib. Really demoralizing and disabling. Angie Weidinger:
People often, we were talking about sometimes get depressed because they can’t do the
things they normally could do, right? Dr. Mitchell Faddis:
Exactly. Angie Weidinger:
Like a game of golf would completely take it out of you. Dr. Mitchell Faddis:
That’s a very good point. A lot of the treatments focused on a-fib are
for people that are the most symptomatic. And I think the way it’s disrupted their
quality of life, the things they want to do, but can’t do. Keeping up with grandkids or children are
common complaints that I hear. Angie Weidinger:
So, what are some of the treatments that people can have for atrial fibrillation? Dr. Mitchell Faddis:
Well, the most important and the one that I think a lot of people are aware of is blood
thinners. And in general, a-fib, atrial fibrillation
accounts for probably as much as 1 in 3 of the strokes that happen. And our best way to protect people against strokes it to use a blood thinner. Angie Weidinger:
OK, which has its own side effects, right? Dr. Mitchell Faddis:
It has its own side effects. Now the impact of other treatments aimed at
the a-fib on stroke is really uncertain at this point. And so by far and away, the most important
treatment in patients with a-fib who are indicated for a blood thinner is to take that blood
thinner. Now some people can get away with an aspirin
or can’t tolerate a blood thinner and aspirin may even be too much in that group. So that’s where there’s opportunity for
new technologies to help with. But the focus that we’re going to talk about
today is actually in preventing a-fib or getting rid of the a-fib. And there’s a host of treatments that go
along that line. Angie Weidinger:
So let’s talk about that. Some exciting technology that we’re kind
of surrounded by. What is kind of innovative in this arena? Dr. Mitchell Faddis:
Well, this is a great room to do this session in, because it shows some of the equipment
that’s important for us to be able to see the inside of the heart and to use that information
to guide a specific treatment called catheter ablation. And it’s fair to say that’s a minimally
invasive, but not completely non-invasive, but a minimally invasive treatment where we
try to disrupt that electrical chaos that’s going on in the upper parts of the heart. Angie Weidinger:
OK, and so how, how, what then happens? How are you disrupting this electrical chaos? Dr. Mitchell Faddis:
Well, the, the main principle of the treatment in the last 10 years anyway, has been to create
a boundary, like a fence, around the most active parts of the heart that generate the
atrial fibrillation. We call that pulmonary vein isolation. And that remains the most important piece
the catheter ablation technique. But unfortunately, that has not proven to
be terribly effective at dealing with the majority of people who have atrial fibrillation
that’s continuous. And in that group, we’ve looked at a variety
of different approaches. But the most promising one, one we’re going
to talk about today, is to actually try to map the patterns of the electrical activity
as they exist in the atrial fibrillation and to see within that, little tornados, little
hurricanes, since we’re in hurricane season, of atrial fibrillation. And it turns out those little hurricanes are
positioned in particular areas. If we can spot them with the mapping system
and that ablation or burning on the inside of the heart in those zones, well, we’ll
be able to get rid of the atrial fibrillation. Angie Weidinger:
And that’s, so you’re referring to this rotor mapping? Is that what it’s called? Dr. Mitchell Faddis:
That’s right. Angie Weidinger:
And that’s what we’re seeing here on this screen, right? Dr. Mitchell Faddis:
Yeah, this is a– Angie Weidinger:
Tell me about; what are we seeing here? Dr. Mitchell Faddis:
It’s a great example. So this, this map that I have here is generated
in a patient with atrial fibrillation. And we positioned a mapping catheter, which
is a basket. Angie Weidinger:
So this basket that we’re seeing right here, how is that, that’s in the heart. Dr. Mitchell Faddis:
On the inside of the heart. Angie Weidinger:
How does that; how are you getting that inside the heart? Dr. Mitchell Faddis:
We pass it through essentially a soda straw-like structure called a sheath. And once outside of that sheath, it inflates
like a balloon. But you haven’t opened up, this is not a
surgery. It’s not, you didn’t have to open up the
chest or anything. This came through the groin. You can pass it up? That’s incredible. Dr. Mitchell Faddis:
That’s right, we can go through an IV in the leg and it reached the right place in
the heart. And then as that expands and makes contact,
we get access to the electrical activity, we can see that. And with this high powered computer and the
software, we’re able to display that electrical information in a pattern that we can see and
analyze. And what we’ve done here is, with the help
of the software, highlighted a particular area of the inside of the left atrium where
there is rotational activity. These little red spots. It’s like a weather map. You mentioned that. Angie Weidinger:
It looks just, to me, when he first showed this, what are, what are we looking at here? Dr. Mitch Faddis:
Yeah. Angie Weidinger:
The colors help out tremendously. But it looks like a weather map where the
activity, obviously the red, indicates a lot of activity. Right? Dr. Mitch Faddis:
That’s right. So the white, the areas that are sequentially
white, are the front of a wave front, like a wave of electrical activity. And the computer is highlighting here a particular
area where those wave fronts are just spinning around repetitively. And that is a rotor right here. So this is what we would call the core of
the rotor. And that would be a target for catheter ablation. Angie Weidinger:
So basically, when you see something like that, what’s happening there that’s causing
problems? That’s the elec-, explain what that electrical,
what’s happening? I want to understand. Dr. Mitch Faddis:
That’s a great question. And it’s fair to say we don’t have a great
understanding of why particular areas are prone to these rotors. Because you would think if you spin a top
and turn it loose on a desktop, it tends to just sort of wander around and go wherever
it wants. Well, these rotors don’t do that. They tend to sort of position themselves in
particular areas. And we think that’s because of potentially
a little piece of scar that sort of tethers the rotor to the edge of the scar. Angie Weidinger:
Oh, interesting. Dr. Mitch Faddis:
Or that the electrical characteristics of that area of the heart are such that rapid
electrical activity is supported, where other areas may not be able to support rapid electrical
activity. Angie Weidinger:
So that’s why, then you know specifically where to go and then, what do you do then? Once you identify that this is where all this
activity is happening, then what, then what happens? Dr. Mitch Faddis:
Well, as you’re pointing out here, a big part of the procedure is to map the lay of
the land and to see what’s active and what’s important. And once we found out where on the inside
of the heart the hotspot is, we move the ablation catheter to that place and actually sequentially
burn all of these areas to try to get rid of the electrical properties in that area
and the places that we abate will form scar that hopefully isn’t electrically active
in the future. But then we map again and make sure that that
rotor activity, those little hurricanes, are no longer there. And in the best case, while ablating the rotor,
we can see atrial fibrillation just collapse and go away. Angie Weidinger:
Wow. So interesting, you are, we’re showing you
footage of, this is actually a procedure that’s taking place. You said you do about how many of these in
a year? Dr. Mitchell Faddis:
About 250. Angie Weidinger:
About 250, and this is a procedure that like you said, the mapping and the ablation, it
takes quite a bit of time, doesn’t it? Dr. Mitchell Faddis:
It does. If we include the rotor mapping, it does generate
a longer procedure, but we hope more effective. And certainly, that’s been our experience
with it. That for persistent or continuous atrial fibrillation,
the outcomes are better. If we add this rotor mapping, together with
the pulmonary vein isolation. On the screen that’s showing the procedure,
you’re actually seeing an area where rotor mapping has been carried out and that little
black circle is the area like where these red spots are. Angie Weidinger:
So like you said, generally speaking when you go in, it’s not just a one spot. We’re not just seeing one of those little
rotor activity. You see several of those usually? Dr. Mitchell Faddis:
Yeah. That’s true. We map both the right upper chamber and the
left upper chamber. And we’ll typically see something on the
order of four in each patient. Angie Weidinger:
Really? Dr. Mitchell Faddis:
Some more, some less. But we’ll try to take care of each of those
rotors individually, one at a time. Angie Weidinger:
Now, if you have questions out there, please, comment. Put those in the comments, because we’re
here to answer, he is here to answer those for you. And we’ll get to those. It’s such an interesting procedure. So once people have this done, is there any
kind of side effect? I mean, for me when I hear, oh my goodness,
this ablation that’s destroying part of, not destroying, but changing parts of that
heart, it sounds a little scary, but it actually has amazing benefits, right? Dr. Mitchell Faddis:
Yeah, I think that’s, it’s a good point. And it’s fair to say that we are creating
a scar, so— Angie Weidinger:
A scar. Dr. Mitchell Faddis:
So the thing that we’re ablating, the heart muscle that we’re ablating, has a very dramatic
electrical impact on the function of the heart. And the mechanical impact that a very small,
I wouldn’t say microscopic, but certainly on the order of the head of a pencil, that
much heart tissue isn’t very meaningful in a mechanical sense. But electrically, it can drive the entire
show in terms of what’s causing the A-Fib. So it is a trade-off, but I think it’s a
reasonable one. Angie Weidinger:
And like you said, this is something for someone who is active. And after this, like you said, we’re not
opening up the chest. This is something that’s minimally invasive. Are they getting back to their regular activity
fairly soon after this happens? Dr. Mitchell Faddis:
That the goal. And I think the experience with it that I’ve
seen in patients is that recovery is pretty quick. Most people feel fairly normal the next day. Angie Weidinger:
That’s incredible. Dr. Mitchell Faddis:
And certainly by a week out, I ask them to return to usual activity. So we hope that we’re doing this to allow
them to have a better quality of life, not to have symptoms that are limiting and they
can get back to that as soon as possible. Now, healing is another matter. And what we create with ablation is an injury
to the heart. And what we want to come from that is a scar
that’s permanent and long-lasting. And that transition from the injury to a healed
heart that no longer will support A-Fib, that takes probably two to three months. So there is the healing phase, the inflammation
that goes with that. Sometimes A-Fib can happen while the healing
is happening. That can be frustrating. Sort of describe that as a part of the package. And probably half of the patients will have
some A-Fib early on as it sputters along. But we hope for a long-term outcome, the cure
in the long-term. Angie Weidinger:
Yeah. So this is this rotor mapping. The rotation, rotor. Took me a minute to figure that out. That rotor mapping, this is something that’s
generally new? Basically new? Dr. Mitchell Faddis:
It is new. It was developed, a scientist who actually
did his training here, Sanjiv Narayan, came up with the idea and developed this particular
version of a company that allows for the mapping. And it’s now been used across, worldwide. And it’s fair to say that it’s an important
new part of the treatment for A-Fib. Dr. Mitchell Faddis:
And we haven’t had a lot of major breakthroughs in the A-Fib realm for I would say the last
five years anyway. Small incremental developments, but I would
view this as a revolutionary technique. Angie Weidinger:
Well, when we talk about revolutionary techniques, this is Washington University Barnes-Jewish
Hospital, this has been a place that a lot of those innovations have been made and refined,
right? Because there’s another procedure that was
founded here. Dr. Mitchell Faddis:
That’s right. Yeah, maze surgery was developed by Jim Cox
in the ‘80s and at team of scientists that work with him, John Bueno, in particular,
who developed a surgical technique that allowed for curing atrial fibrillation by creating
a series of surgical incisions that were cut and then sewn in sequence. And the result of that was to divide up the
upper chambers of the heart and a narrow corridor, a maze, where the electrical signal could
get to where it needed to go. But that the little eddies and swirls or tornados
were not allowed to form, because the corridor was too narrow. Angie Weidinger:
So is that kind of the, this is all built upon a bit? Dr. Mitchell Faddis:
Some of, certainly the pulmonary vein isolation that we do is from the maze, directly from
the maze surgery set of ablations. But the actual rotor mapping is different
from the maze. It may be why the maze is effective, but basically
does not allow for rotors to develop. But I think that it’s hard to minimize how
important the work that led to the maze. ‘Cause prior to that, most people did not
think A-Fib was curable by anything, really any technique. Cardio versions could be done, which is an
electrical shock and that does reset the rhythm in many people. Some people, even that doesn’t work. But the A-Fib tends to come back, and that’s
the most important aspect to A-Fib. Angie Weidinger:
So the benefit of this rotor mapping, before you had the rotor mapping, was it, how did
you know where to go and do the cardiac ablation? How did you know where to go? Dr. Mitchell Faddis:
Yeah, that’s a great question. And it’s fair to say that there have been
a lot of idea about how to do that. And mostly, they have not panned out very
well. So early on, as in 17, 18 years ago, trying
to ablate the things that were most active and to limit the ablation to that was done,
unfortunately, the recurrence rates were high. Because it was like whack-a-mole. You might get one spot one day and then it’s
another spot nearby that pops up the next day. Angie Weidinger:
Right. Dr. Mitchell Faddis:
So then the more regional technique then. That’s the pulmonary vein isolation. But even that wasn’t enough. And so looking at individual electrical signals
and trying to make sense of what those look like, since with a catheter, we can really
just record one or two or three or four at a time. That was used, and techniques developed to
use that as a guide for ablation. The trouble is, the heart’s a big place,
and there’s lots going on. And so the panoramic or global mapping that’s
available to us from these basket catheters is just completely different from what we
could get with a single catheter. And I think that’s where the strength of
the procedure is. Angie Weidinger:
So interesting. We have a question. They’re asking, are blood thinning meds
required after ablation? Dr. Mitchell Faddis:
That’s a great question. It’s critical early on, because we’ve
created an injury on the inside of the heart. And that injury will grow a scab just like
a cut on your skin and could generate a clot that would cause a stroke. Now outside of the ablation and the healing,
then we have to resort to other indications about whether or not a blood thinner is a
good idea long-term. And we look at things like how old, the older
you are, the higher the risk of stroke. If you have diabetes or hypertension. If you have coronary disease or vascular disease,
if you’ve had a stroke before. All those things contribute to a risk that’s
ongoing in spite of what we can do with catheter ablation. And we use those factors to judge whether
or not you need a blood thinner long-term. Angie Weidinger:
When we talk about cardiac ablation, what kind of success rate are we talking about? Dr. Mitchell Faddis:
We can, with this technique right now, we’re seeing about a 75% one-year cure rate in our
series of patients that we’ve done here. We certainly do it a second time if patients
don’t have a great result and have more A-Fib. And I think with one or two procedures, we’re
in the range of 80% at a year off of drugs. And it’s not as effective as maze surgery,
but it’s minimally invasive. It’s certainly reasonable and a great technique
for people that get a cure out of it. Angie Weidinger:
We have another question. If you’re suffering from A-Fib or experiencing
symptoms, what should you do? Dr. Mitchell Faddis:
I think you should see a cardiologist as a first step, just to make sure you’re channeled
into the right path to get the treatments that are available right now at the cutting
edge. Certainly the blood thinner decision is an
important one to make right off the bat. And I think any cardiologist in general would
be equipped to make that decision. Angie Weidinger:
Very good. And again, talk about some of the things that
you would be exper–. We talked about them earlier, but again, some
of the things that you’re experiencing that might be a good reason to go see a cardiologist. Dr. Mitchell Faddis:
Well, the tipoff for a lot of people is a rapid irregular pulse. They get the sense their heart is beating
much too fast, given the activity. And then symptoms like shortness of breath
or all of a sudden patients aren’t able to do simple things, like climbing stairs. Or they had been exercising, but now it’s
hard for them to walk around the block. Angie Weidinger:
It’s just taking it out of them, yeah. Dr. Mitchell Faddis:
Yeah, fatigue. It’s usually not a mystery for most people. Angie Weidinger:
OK, got another question. Would heart medications need to be taken post-procedure? I am currently on, help me out. What’s that? Is that a medication for A-Fib? Dr. Mitchell Faddis:
I think it probably means Toprol or Metoprolol. The A-Fib generally happens in the setting
of other health problems. So hypertension or coronary disease are two
conditions where beta blockers like Toprol are really important. So that drug is sort of killing two birds
with one stone. It’s aimed at the A-Fib, but also aimed
at the other health problems, too. So it’s possible that you would still need
to take Toprol for those other health conditions after an ablation. Angie Weidinger:
What I find so incredible about all of this is this is something you’re not having to
do surgery. That these are teeny tiny tools that you’re
able to send into the heart. It really is amazing, this technology. Dr. Mitchell Faddis:
It has really been dramatic, the evolution of the techniques. I think in medicine and surgery in general,
to miniaturize the therapeutic things to use really innovative ways to look at tissues,
particularly the heart. We have these electrical maps. We also have anatomic maps we can get from
CT and MRI, and we do that typically in every patient who goes through ablation, and import
that into a mapping system. And then we also have a three-dimensional
mapping technique that’s like GPS, where the computer can tell where in three-dimensional
space we’re touching. And we use all of those different pieces of
technology aimed at ablation. Angie Weidinger:
And we have, we really appreciate all your questions. But we’re going to have this video living
online. And please, answer, ask more questions. We’ll get someone to answer those for you. Also, there’s a form. If you have questions about atrial fibrillation,
you can fill out the form. We’ll have a heart specialist get in touch
with you, answer all your questions. So that’s a great resource for you to use. There’s so many things to talk about, so
many different procedures and things that are done here and more innovations, I’m
sure, that’s being worked on. So it’s really an incredible field that
you work in. Dr. Mitchell Faddis:
Thank you. Angie Weidinger:
Yeah, very interesting. Thank you for helping us with all these questions
that we had today and it’s been a really fascinating conversation. Dr. Mitchell Faddis:
Thank you, Angie. Angie Weidinger:
For welcoming us in, we appreciate it. And keep asking those questions and we’ll
see you on our next Facebook Live event. Thanks for joining us.

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