EMERGING TECHNOLOGIES AND TECHNIQUES

Unveiling new possibilities in the treatment of atrial fibrillation

Choi Eue Keun, Professor, Internal Medicine (Division of Cardiology) Seoul National University’s College of Medicine

Emerging technologies and techniques are unveiling new possibilities in the treatment of atrial fibrillation (AF), such as improvements to procedural times and outcomes through the use of Visitag Surpoint® (previously known as Ablation Index) guided high-power ablation, as shown in a recent study led by Choi Eue- Keun. Against a backdrop of heart-related complications emerging among patients infected with COVID-19, there is now a greater urgency for healthcare professionals to advance the efficacy of AF treatment.

How is the growing incidence of atrial fibrillation impacting population health across Asia-Pacific?

Atrial fibrillation (AF) is a growing epidemic that affects over 16 million people in the Asia Pacific alone1. This number is only expected to increase, reaching as high as 72 million by 20502,3, due to ageing populations and increased incidence of lifestyle-related risk factors, such as obesity, physical inactivity, and hypertension.

AF has detrimental consequences and can negatively impact one’s quality of life as well as increase the likelihood of other debilitating conditions such as stroke, heart failure, and cardiovascular mortality. It also places a substantial burden on healthcare systems. Direct costs have increased exponentially over the past two decades. With Asia-Pacific expected to see more than twice as many AF patients than Europe and North America combined, the burden of the disease is expected to be far greater than in any other region4.

Now more than ever, there’s a need for all healthcare professionals to explore how we can optimise the treatment of AF to improve patient outcomes and ultimately reduce the financial burden.

What challenges do physicians face in treating atrial fibrillation?

AF is often associated with morbidity and mortality, and timely diagnosis and treatment challenges largely drive this. If left untreated, patients face an increased risk of disease progression and further complications. For 20 per cent of patients, the condition typically progresses from intermittent to persistent AF within a year of diagnosis5,6, and potentially leads to the structural remodelling of the heart, therefore making it harder to treat.

Early intervention of AF is crucial in preventing the worsening of symptoms, reducing the likelihood of arrhythmia recurrence, and improving quality of life in the long run. However, some patients present no symptoms, leading to difficulties in diagnosis and increased prevalence of untreated risks for morbidity and mortality. Furthermore, despite close to half of the patients in Asia-Pacific struggling to manage their condition through anti-arrhythmic drugs (ADD)7, awareness towards related procedures remains low. This in turn hampers timely intervention.

In addition, many primary physicians have regarded AF as a non-treatable disease, thus choosing to not pursue rhythm management. This approach eventually leads to permanent AF. Education on this condition is therefore needed for primary physicians to perform appropriate therapy in patients with newly diagnosed AF.

Has the onset of COVID-19 impacted patients with atrial fibrillation or treatment in any way?

A growing number of studies reveal direct correlations between COVID-19 and cardiovascular complications, including arrhythmias, heart failure, and blood clots, all of which are accompanied by an increased risk of adverse outcomes8. Similarly, patients who suffer from existing cardiovascular conditions are at greater risk of morbidity and mortality when infected by COVID-19 due to the presence of infection in the heart and lungs.8

Therefore, treatment of AF should not be delayed, even amidst the global pandemic, as it places patients at greater risk and can potentially reduce the success of outcomes. In addition, more attention should be given to cardiovascular protection during the treatment of COVID-19.

What are some of the common procedural techniques used for rhythm management?

AF is characterised by an irregular and often fast heartbeat that results in uncoordinated contractions of the atria. Catheter ablation is one of the common procedural techniques adopted to treat this condition by blocking abnormal electrical signals that cause arrhythmia.9,10, It is highly effective in reducing arrhythmia recurrence as well as the long-term risks of AF-related complications, including stroke and heart failure. Patients are also 10 times less likely to develop persistent AF than those who opt for ADD, as demonstrated by the Atrial Fibrillation Progression Trial (ATTEST)11, and in the long run, rely less on medication.

Pulmonary vein isolation (PVI) is also a widely accepted treatment strategy for catheter ablation, and over the years, it has undergone significant evolution to optimise clinical success and minimise the risk of complications.

We are now seeing an influx of new technologies and techniques in the healthcare space. What are some of the latest solutions used in the treatment of atrial fibrillation?

Recent technological advancements in catheter ablation have allowed healthcare professionals to achieve a more effective and safer PVI. The use of an automated tagging module, such as the VISITAG SURPOINT®, annotates the ablation site objectively whenever predefined criteria such as catheter stability, time or contact force are fulfilled12,13. Since its introduction, several studies have highlighted the efficacy and safety of these solutions.14

On the back of new findings around ablation procedures, I led a study titled Acute and long-term efficacy of ablation index-guided higher power shorter duration ablation in patients with atrial fibrillation: A prospective registry, to explore the efficacy of PVI using high power catheters guided by the solution. Through the research, we were able to ascertain that the use of increased power during AF ablation reduced the procedural time by 30 per cent and can be performed safely using an automated lesion tagging module. The technique also resulted in comparable acute pulmonary vein reconnection rate and long-term survival without significant complications within a four-week and one-year time frame, compared to conventional-powered PVI.

How do such techniques and/or innovations help to optimise treatment outcomes?

Advancements in techniques, as seen from our recent study, coupled with innovations from industry players such as Biosense Webster have unveiled new possibilities in the treatment of AF.

With prevalence on the rise, continued advancement of treatment options will help healthcare professionals to achieve long-term outcomes that ensure their patients are able to live their best lives possible. In the context of AF treatment, this refers to freedom from symptomatic arrhythmia recurrence and improved quality of life. Deploying the right treatment approach also allows physicians to optimise the use of resources and reduce the burden on healthcare systems.

References:

1 Global Burden of Disease Collaborative Network (2017) Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2017. Accessed 2019-07-16. Available from http://ghdx.healthdata.org/gbd-results-tool
2 Wong CX, Brown A, Tse HF, et al. Epidemiology of Atrial Fibrillation: The Australian and Asia-Pacific Perspective. Heart Lung Circ. 2017;26(9):870-879.
3 Chiang CE, Wang KL, Lip GY. Stroke prevention in atrial fibrillation: an Asian perspective. Thromb Haemost. 2014;111(5):789-797.
4 Chiang CE, Okumura K, Zhang S, et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm. 2017;33(4):345-367.
5 Nieuwlaat R, Prins MH, Le Heuzey JY, Vardas PE, Aliot E et al. (2008) Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. Eur Heart J 29 (9): 1181-1189
6 Schnabel R, Pecen L, Engler D, Lucerna M, Sellal JM et al. (2018) Atrial fibrillation patterns are associated with arrhythmia progression and clinical outcomes. Heart. Oct;104(19):1608-1614
7 Wang KL, Wu CH, Huang CC, Wu TC, Naditch-Brule L et al. (2014) Complexity of atrial fibrillation patients and management in Chinese ethnicity in routine daily practice: Insights from the RealiseAF Taiwanese cohort. J Cardiol 64(3):211-217.
8 Samidurai, A., & Das, A. (2020). Cardiovascular Complications Associated with COVID-19 and Potential Therapeutic Strategies. International journal of molecular sciences, 21(18), 6790. https://doi.org/10.3390/ijms21186790
9 Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D et al. (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37(38):2893-2962.
10 Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB et al. (2017) 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 14(10):e275-e444.
11 Kuck KH, Lebedev, D., Mikaylov, E., Romanov, A., Geller, L., Kalejs, O., Neumann, T., Davtyan, K., On, Y.K., Popov, S., Ouyang, F. (2019) Catheter ablation delays progression of atrial fibrillation from paroxysmal to persistent atrial fibrillation. ESC Late-breaking Science 2019. Paris, France. August 31, 2019.
12 Cho, M.S., Kim, J., Do, U. et al. Clinical outcomes after pulmonary vein isolation using an automated tagging module in patients with paroxysmal atrial fibrillation. Int J Arrhythm 21, 13 (2020). https://doi.org/10.1186/s42444-020-00021-9
13 El Haddad M, Taghji P, Phlips T, Wolf M, Demolder A, Choudhury R, et al. Determinants of acute and late pulmonary vein reconnection in contact force-guided pulmonary vein isolation: identifying the weakest link in the ablation chain. Circ Arrhythm Electrophysiol. 2017; 10(4):e004867.
14 Taghji P, El Haddad M, Phlips T, Wolf M, Knecht S, Vandekerckhove Y, et al. Evaluation of a strategy aiming to enclose the pulmonary veins with contiguous and optimized radiofrequency lesions in paroxysmal atrial fibrillation: a pilot study. JACC Clin Electrophysiol. 2018; 4(1): 99– 108.

--Issue 54--

Author Bio

Choi Eue Keun

Choi Eue-Keun is a Professor for Internal Medicine (Division of Cardiology) at Seoul National University’s College of Medicine. He is an author of over 240 peer-reviewed journal publications and book chapters and has been presented the ‘Best Paper Award’ by the Asian Pacific and Korean Heart Rhythm Society in 2010 and 2015 respectively. Dr Choi is an active member of several national medical societies, including the Korean Society of Internal Medicine and Cardiac Arrhythmia.

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