Two decades of development in AF treatment and education

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Mark O’Neill

This year marked the 20th edition of the Atrial Fibrillation Symposium (AFIB2022; 24–25 May, Copenhagen, Denmark) which, over its lifetime, has evolved to become one of the leading events in the calendar for atrial fibrillation (AF) specialists. Mark O’Neill (St Thomas’ Hospital and King’s College London, London, UK), who has sat on the event’s organising scientific committee alongside Mattias Duytschaever (St Jan Hospital, Bruges, Belgium) and Dipen Shah (University Hospital of Geneva, Geneva, Switzerland) spoke to Cardiac Rhythm News about how the event has reflected the changing approaches to AF treatment over its two-decade lifespan.

Looking back over the last 20 years, how has understanding of the diagnosis and treatment of AF evolved, and how has this evolution been reflected in changes to the AFIB Symposium during that time?

Everything began with the refinement of radiofrequency (RF) ablation for pulmonary vein isolation (PVI), which was addressed in the first three or four editions of the symposium. This was a very new field at the time, with the first published observation of a potential mechanism for atrial fibrillation (AF) in 1998, which then led to the development of a therapy. That observation was the recognition of pulmonary vein ectopy as a potential trigger for AF.

Then the field started to grow into other elements of electrophysiology (EP) that it was thought might help to develop alternative targets for treating AF. Electrical target hunting became the vogue for several years, with a focus on measured electrical abnormalities within the heart, on to signal processing techniques aiming to derive information from the signals recorded within the heart that might point towards specific targets away from the pulmonary veins.

In parallel with all of this conceptual change, engineers were working furiously to develop technologies that could allow both interpretation of electrical phenomena as well as tools to treat targets, and we started to see the emergence of new ablation technologies with the development of laser balloon ablation, cryoballoon ablation, and refinement of RF ablation up to the point where we are now.

In the last five years, the emphasis has been more on patient selection and how we best prepare a patient with AF for the management of this condition. In some patients that will be a real focus on trying to address the risk factors that cause their AF, while in other patients the focus will be on delivering an effective procedure.

I think that what we are currently seeing in the field of AF is what we saw in the field of coronary artery disease 20 years ago, which was preceded by a period of cardiac surgery being the main way to treat patients. This changed with the introduction of really effective medical therapy and the parallel development of technologies that allowed percutaneous intervention. We are seeing a similar paradigm playing out in the management of AF.

Have the changes in the treatment of AF influenced the way that the content is delivered at AFIB Symposium?

There is a very traditional, didactic approach to the communication of educational material, but it is one that works, and symposia have followed this outline for many years. If you look at the AFIB Symposium 20 years ago, it was focused on the delivery of lectures from experts in a lecture theatre, and 20 years later, we still have that in-person engagement and sharing of ideas and knowledge face-to-face. It was great to return to that format this year after the past two years, and show the practical advances that have been made. However, over the course of the last few years, accelerated by the pandemic and the necessity to move to a completely virtual delivery platform, it has pushed us to think a little bit more about how we transfer that information.

The content is very important, but if the content does not lead to somebody listening, registering, processing and changing, then it is useless. It must be delivered in a way that creates change. The Symposium has started to move with the times, and it is now a hybrid symposium—drawing on the benefits of each format, tailoring it for our audiences and making it accessible.

How well received was the switch to a hybrid model and will that be a lasting change?

Looking to the future, it is inevitable that if we want to reach as wide an audience as possible, the event needs to have a hybrid component. The people who can attend in person are the privileged few, and we need to be making it more widely accessible, as highlighted by the pandemic.

A modern-day symposium, which is focused on a single condition, has to provide value across the spectrum of that condition. AFIB Symposium was set up 20 years ago as a physician-centred meeting, but it has gradually evolved. A good example of this evolution is one of the highlights of this year’s meeting—the Women in EP lunchtime breakout group—where we had 92 women attend to discuss challenges and opportunities and the future of their participation in what has been largely a male-dominated subspecialty for a very long time.

Patients with AF are looked after everywhere, not just by EPs in cath labs, and while the symposium has really focused on the common goal of the catheter ablation procedure, it has a responsibility to look across the AF patient population. In the future, the team and the Symposium should consider an event that informs entire healthcare teams about how to deliver the best ablation outcomes. That will mean involving nurses, physiologists, even trainees in electrophysiology in the discussion on how best to do that within the constrained resources of a healthcare system.

What are the important themes to have emerged from this year’s event?

The outline of the symposium is broken into two basic blocks, one of which is evidence and another of which is therapy. We have tried to merge these so that the communication is of evidence-informed therapy, rather than just the description of techniques and technologies.

The key themes of the event included the translation of insights into mechanisms of AF, though there is not much new in that area to inform us about the mechanism of AF as it pertains to delivering a target for treatment. There has been real focus in the field for many years on the management of persistent AF, and we discussed whether treatment should be tailored to the patient or whether it should be a one-size-fits-all procedure.

We spoke again about early rhythm control, and I think this is going to be a key feature of the management of patients with AF moving forward. We also discussed screening and early management of AF.

From the technology point of view, two key themes emerged. One was the evolution of technologies to ablate cardiac tissue, principally RF energy, and we discussed how that might be better delivered. The hottest topic this year—as it was last year and probably will be next year—is that of electroporation. This is a novel technology for the application of intermittent high-intensity electric fields for very short periods of time which injure cardiac tissue in a very different way to more conventional thermal tools.

I am glad we are doing this in a very measured way and not jumping on a bandwagon with a new technology, believing that we have the answer. Having said that, this is a technology that looks like it satisfies a number of key criteria like reproducibility, safety and durability.

What will be other key developments that will shape the focus of the symposium in the future?

Outside of the business end of doing the ablation procedure, the most important patient-related advances that we have seen over the last 10 years are the introduction of novel anticoagulants and proof of their safety and widespread applicability, improved patient selection, and minimisation of complications related to the procedure. Looking forward, the key questions that are interesting and at the same time confusing and need further thought are how do we get to a target in cases of persistent AF, what does remodelling mean, what does AF do to the heart and can we undo it by means of a tablet, a physical therapy or an intervention?

If we look at the wider picture societally in terms of AF diagnosis, in the UK in 2014/15 the National Health Service (NHS) spent £6bn on treating obesity-related ill health, and that is forecast to rise to about £10bn by 2050. The societal cost for obesity in the UK is about £58bn, so that is about 3% of our entire GDP. Obesity is also associated with hypertension and sleep apnoea, which together are major risk factors for AF. We know that the incidence and prevalence of AF are both climbing and we know that the incidence and prevalence of the risk factors that cause AF are all climbing, so in fact what we need to do is not to focus on the end result but focus on the risk that is leading to the end result. Changing the health of a population takes years, if not decades.

I think that there is going to be a slow burn on treating our AF epidemic. The focus really does need to be upstream, rather than downstream on the therapies that we use to treat the very small minority of patients who come to having a catheter ablation procedure, because we do not have (and never will have) the capacity globally to treat everyone with an ablation—and nor should we.


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