TRENDS IN THE TREATMENT OF AF (2009)

Routine use of more than one treatment procedure: for example, a CA or surgery followed by a touch-up ablation, as in Richard Lee's hybrid approach and the convergent approach of Dr Natale.

 

Tailoring the treatment to fit the individual, with regard to: type of AF (Intermittent vs. Continuous) or the location of the aberrant impulses, as is done by Drs Marchlinski, Morady and Drs Jais and Haissaguerre at Bordeaux (see the 2006 Boston Symposium). The former will require more research on treatments for patients in different diagnostic categories; the latter will benefit from improvements in EP mapping.

 

Discovering and dealing with the more basic causes of AF, such as: genetic factors,  inflammation, autonomic nervous system dysfunction and learning how to determine additional factors such as events or substances that trigger AF in susceptible individuals.

 

The use of robotics to make the surgery less invasive and to make both CA and surgery less subject to human error. It will also reduce the learning curve, meaning that success will be less dependent of the skill of a relatively few gifted artists.

 

The use of improved imaging techniques, which can allow the EP to "see" well. It will reduce the advantage the surgeon gets from making an incision large enough to directly view the area on which he is working.

 

The development of new medications that could, in theory, make both CA and surgery for AF necessary for fewer patients.
 
Sorting out the usefulness of statins, ACE inhibitors and supplements in treating and preventing AF.

For more on Trends, see the Keeping Up part of the Resources section. I find the reports of the Boston Symposia accessed on the left sidebar of the a-fib.com website especially useful.

Late addition (Spring 2010) Interview with Dr Andrea Natale on new developments:

Mellanie True Hills: This is Mellanie True Hills, from Stopafib.org, I'm at Boston Atrial Fibrillation Symposium 2010, and I'm talking with Dr. Andrea Natale, whom many of you know as one of the rock stars of the catheter ablation space. He has agreed to share with us about some of the future directions for catheter ablation and the afib space. Dr. Natale is the executive medical director of the Texas Cardiac Arrhythmia Institute at St. David's Medical Center in Austin, Texas, and also practices at some other locations around the country. Dr. Natale, thank you so much for joining us today, and we're excited to know what are some of the future directions for catheter ablation and for treating afib patients?

Dr. Andrea Natale: Thank you, Mellanie, for this opportunity. There are two main things we have learned in the last few years that relate to the difficult group of patients, which are the patients with long-standing persistent atrial fibrillation. We have learned that, in that group, we really have to try to individualize the approach to be able to target areas that really are outside of the conventional region that we address in the typical patient. And because of that, catheter ablation in some of these patients might have some limitations, so we recently explored what we call "hybrid approaches", which are procedures where we combine the benefit of the surgical minimally-invasive strategy and the catheter-based strategy.

There are two ways we are doing this today. We are a little bit more experienced with the product produced by nContact, and we're now in the process of finalizing the protocol with another company, AtriCure. The philosophy is to really combine the advantages of both procedures. Obviously, this is something that is difficult to predict the way it is going to pan out, but we sort of are hopeful that at least we're going to learn what is best for the patient. Honestly, I feel that we're going to be able to do better than what we do with either catheter-based alone or a surgical procedure alone. So I'm somewhat excited about this opportunity because it is going to really help us to manage more efficiently a patient with more difficult atrial fibrillation.

MTH: Are there any other really exciting things on the horizon that you'd like to share with us?

Dr. Natale: Well, from our perspective, I think contact force [sensing] is something that we realize is very important to try to improve what we do with catheters. One of the issues that we have with catheter-based procedures is that the lesion that we create is not necessarily permanent, and this affects the success rate. If we have a way to assess the contact between the catheter and the tissue, that can help us to do a better job. So I'm confident that this technology is going to improve the efficacy, and maybe the safety, also, of catheter-based procedures. So that's one area. The other regions of importance, especially in the non-paroxysmal patient, such as the coronary sinus and the left atrial appendage, are areas where you want to know how much pressure you apply to the tissue, because if you do too much, that certainly can result in a complication. So I see this as a tool that is going to be valuable to people who perform catheter-based procedures.

MTH: Excellent. Dr. Natale, thank you so much for sharing with us today. This is Mellanie True Hills, for StopAfib.org.