A Report from Western AF: The Tide Is Changing

John Mandrola


March 03, 2015

It was an honor to speak at the Eighth Annual Western AF Symposium in Park City, UT. Western AF is always a great meeting, but this year it was special. Something big happened. You could sense it in the room and in the conversations.

Mainstream electrophysiology gets it: AF is a symptom of a systemic disease.

At Western AF, giants in the field of electrophysiology, from Indianapolis, Philadelphia, Salt Lake City, Chicago, Cleveland, Boston, Australia, Germany, and the Netherlands all stressed that doctors who treat patients with AF must first treat cardiovascular risk factors.

You have heard this before, but never from the leaders of the field.

It all fits.

Consider these three questions:

  • Why have the results of AF ablation—for anything other than the rare case of focal AF—been so dismal?

  • Why would a panel of eight electrophysiologists describe different techniques for ablation of the same disease—persistent AF?

  • Why would we see atrial fibrosis and atrial electrical disease progress after successful ablation? (Pause on that one.)

It is simple. Because the atria reflect the health of the human being.

Dr Nassir Marrouche and his team at University of Utah organize Western AF, so the meeting reflects their research interests in fibrosis and imaging. We heard talks on how fibrosis affects the electrical function of the atria. It surely does, but where does the fibrosis come from?

We learned that high left atrial pressure, from, say, hypertension, obesity, sleep apnea, and maybe even endurance exercise, induces myocytes to lay down fibrosis. We heard that a bad night's sleep affects gene expression, and pericardial fat releases profibrotic cytokines.

Dr Kalyanam Shivkumar (University of California Los Angeles) taught us that the heart has its own—intrinsic—nervous system. Our heart feels stuff, is what I heard. (Just typing that feels good.)

We also heard this gem: weight loss and risk-factor management improve atrial electrical function—not just in sheep, in people!

These lessons explain why a procedure that creates more scar will never be the answer for a disease that stems from scar.

The take-home is this: when AF appears, it is sign that the atria is distressed. The answer, therefore, is to treat the problems that cause the distress.

A good doctor sees the problem, and then treats that problem.

Of Course It Is Hard

Now to the response that always arises when I report this news.

Dr Marrouche asked me the standard American-doctor question: "Okay, John, we now know lifestyle factors are critical, but how do we put this into action?"

My answer is leadership. Doctors, especially specialists, should take the lead. It is a top-down message. It is on those of us who wield the catheters. And it is not an easy message.

It is hard to change human behavior. It is hard to tell patients their way of life led to this problem. It is hard to go against market forces that favor procedures. And it is really hard to do all this in a short office visit, one made even shorter by electronic medical records.

Yet we fail, spectacularly so, if we substitute an expensive, risky, and wrong procedure for a symptom of a wider disease. Dr Greg Feld (University of California, San Diego) said it well in a Q&A session. Reflecting on the history of electrophysiology, he noted that we were successful in Wolff Parkinson White and supraventricular tachycardia (SVT) ablation because we understood mechanisms. We were even okay, he said, when we ablated focal AF from the pulmonary veins.

The problem now is we know the mechanism for most forms of AF—it is end-organ damage from systemic disease. And that is precisely why a catheter is not, nor will it ever be, the only answer.

My take is that heart doctors don't have to be lifestyle gurus. We don't need gimmicks. We just have to see the truth, speak the truth, and target the truth with our treatments. We must also enroll help—and convince our employers to see the value of a team approach for people with AF.

If an AF patient gets mad at this message and goes across the street for a second opinion (or to his primary-care doctor) and hears the same message, then there will be progress. But if that patient goes for a second opinion and hears he can be fixed with a procedure or a device, then the problem remains.



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