Sabine Ernst and Mattias Duytschaever are both consultant cardiologists and scientific committee members of the practical and scientific faculty of the Atrial Fibrillation Symposium, a long-standing initiative from Biosense Webster and the Johnson & Johnson Institute. Here, they talk to Cardiac Rhythm News about their roles at this year’s event (Atrial Fibrillation Symposium, 6–8 February, Copenhagen, Denmark). They also discuss their highlights from this year’s meeting and what they consider are the educational requirements in atrial fibrillation to advance patient outcomes of a condition that is placing an increasing burden on patients and healthcare systems.
What is your involvement with the Atrial Fibrillation Symposium?
Ernst: I have a long association with the Atrial Fibrillation Symposium. During my years as a senior fellow in Hamburg, Germany I worked with the head of cardiology, Karl-Heinz Kuck to support the development of the symposium programme (in conjunction with the other course directors at the time, Michel Haissaguerre and Carlo Pappone). It was when I moved to the Royal Brompton Hospital in London, UK that I became involved in mapping out the practical programme that is aimed at our younger, up‑and‑coming leaders in the field.
Duytschaever: I too have a long-standing association with the Atrial Fibrillation Symposium, having been to every event since the inaugural symposium in 2001. Over the years, my involvement has increased, to the point where I now contribute to the development of the scientific programme.
What are the advantages of having a joint practical and advanced programme?
Ernst: From the beginning, I felt strongly that in a fast-changing field, where new technologies and techniques are regularly trialed and validated, there is an educational need to gain practical experience to confidently perform new procedures as effectively and safely as possible.
A joint programme is an ideal way for consultants and senior fellows to implement their learnings from the sessions the moment they return to their clinical practice.
Duytschaever: When I first attended the Atrial Fibrillation Symposium, there were no practical sessions. In my opinion, combining practical and advanced sessions has significantly shortened the learning curve for training electrophysiologists. Rather than relying on a trial and error-like approach, young cardiologists now have an opportunity to train in a safe and controlled environment.
What have been the key advances shared during the symposium over the years and how have they advanced treatment of atrial fibrillation?
Ernst: Advances in technology have revolutionized atrial fibrillation treatment. We are now able to assimilate ~10,000 data points to construct a high-resolution, three-dimensional electroanatomical map. Advanced mapping technology now allows us to precisely target the cardiac tissue that is causing the arrhythmia, without causing collateral damage; such visual acuity also enables us to carry out the procedure without using fluorescence imaging. The use and practical implications of technology of this kind, working carefully on hand and eye coordination, were a main focus of this year’s practical sessions.
Advances such as these have allowed us to address key challenges in atrial fibrillation, each of which is associated with an educational and training need. When I began my career, “curing” atrial fibrillation was an aspiration. Back then, we had a ~20% clinical success rate—now we are up to over 85% for cases of paroxysmal atrial fibrillation. So significant progress has been made, with the help of events such as the Atrial Fibrillation Symposium.
Duytschaever: During the first decade of the Atrial Fibrillation Symposium, the debate predominantly surrounded the need to electrically isolate the pulmonary vein. This is now beyond question. In my opinion, the major technological advancement over the past 10-15 years has been the ability to establish a durable pulmonary vein isolation, now considered a vital process during catheter ablation. As a result, single-procedure freedom from atrial fibrillation has increased from 60% to over 85% in paroxysmal atrial fibrillation. Together with marked progress in cardiac imaging and patient selection, these advances are expected to improve ablation outcomes in patients with persistent atrial fibrillation.
What were your key highlights and learnings from this year’s symposium?
Ernst: One persistent problem we have had is a restricted view of the ablation site. Sessions from this year’s symposium have, however, demonstrated significant progress on lesion assessment, guiding how much energy we use, for how long, and where to perform the ablation. I was also interested to learn about new suturing techniques that reduce the risk of bleeding from the puncture site, a common complication that can affect up to 20% of ablation procedures.
Duytschaever: From a clinical trial perspective there was the new analysis, long-term follow-up and debate surrounding outcomes from the CABANA and CASTLE clinical trials, and the impact these studies have on clinical practice.1 From a practical perspective, I was particularly interested in the data surrounding electroporation and high-powered, short duration ablation, which appears to be the direction we are heading and preferable from an esophageal safety perspective. Finally, from a purely academic viewpoint, I was interested in the current thinking regarding the role of fibrosis in atrial fibrillation initiation and progression.
Finally, what are the key educational requirements in atrial fibrillation, now and for the future?
Ernst: One specific challenge we face when treating atrial fibrillation is that there is no margin for error. One small mistake can have serious consequences. That knowledge informs the main educational challenge—how to train young clinicians safely and push them, without pushing them too far from their comfort zone. Training the entire multidisciplinary team in as safe an environment as possible, and giving them specific scenario training, is also key to ensuring that in a high pressure, intense environment, the correct response becomes second nature. This is where the hands-on, practical sessions provide real, measurable and lasting value.
We also need to educate our patients. Unreliable sources of information can greatly increase anxiety, in particular in newly diagnosed patients. It is important that our patients are well informed on the ablation procedure itself and also the risk of more serious events, such as stroke and sudden cardiac death.
Duytschaever: From an academic perspective, our major challenge is to improve our understanding of the pathophysiology behind atrial fibrillation that is not mediated in the pulmonary vein. As mentioned previously, we have made great progress in securing durable pulmonary vein isolation, our next challenge is not how to ablate, but to understand where to ablate in patients with non-pulmonary-mediated atrial fibrillation. Finally, we have to address under utilisation of ablative therapy in patients with atrial fibrillation. This can be achieved by informing both the patient as well as the referral centres on the major impact of catheter ablation on atrial fibrillation burden and progression.
The next Atrial Fibrillation Symposium will take place 12–14 February 2020 in Madrid, Spain.
1. Marrouche N. Essential lessons learned from AF ablation mortality trials (ATAAC-AF, CASTLE-AF, CABANA. Atrial Fibrillation Symposium, Copenhagen, Denmark, 24–26 January, 2019.