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Accurate Diagnosis and Efficient Workflow in AF Therapy

How a fast map-ablate-remap strategy influences therapy and procedures?

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How a fast map-ablate-remap strategy influences therapy and procedures?

Catheter ablation of atrial fibrillation (AF) has shown steady growth over the past two decades. According to the European Society of Cardiology ESC, between 2007 and 2016 the number of AF ablations per million inhabitants increased on average by 339% in the European member states of the ESC.1

The prevalence of AF in the US ranges from 2.7 to 6.1 million, with 5.6 to 12 million additional cases projected by 2050.2 According to extrapolations from a 2004–2006 dataset, Medicare spending for new AF diagnoses has reached $15.7 billion per year. The costs are primarily being driven by AF complications such as stroke, heart failure, tachycardia and myocardial infarction.3,4

Additionally, costs for devices and disposable products are also on the rise.5 This is why decreasing the time spent per procedure without compromising the efficacy and safety might be a good starting point to improve outcomes while reducing healthcare costs.

Advantages of fast map-ablate-remap strategies

Documentation from 30 years ago supports that ablation was more cost-effective than a long-term medical treatment, like propafenone, beta-blockers and/or amiodarone, in most cases.6 Since the early days of electrocardiography, new forms of ventricular tachycardias as well as new observations on a variety of supraventricular arrhythmias, atrioventricular conduction disturbances and paced rhythms have been described.7 Remapping allows the physician to confirm the impact of a lesion in the acute procedure. In complex atrial arrhythmias, remapping and ablating more than one trigger leads to a better outcome, which means that a fast strategy for remapping is needed.

Impact of fast-map-ablate-remap strategies

A fast and efficient strategy to map, ablate and then remap allows electrophysiologists to evaluate and identify more substrate and similarly assess the efficacy of their work by looking for gaps or blocks. Using contact-mapping, a map-ablate-remap approach is very time consuming. With current contact mapping technologies, one map takes about 15–20 minutes to really get an idea of the arrhythmia. Therefore, the overall process can take up to 4–5 hours depending on the complexity of the case. In extreme cases, the mapping might even be stopped before every substrate has been discovered, simply because it is taking up too much time and subjects patient and physician to prolonged anesthesia or radiation (if fluoroscopy is being used).

Additionally, reducing the time it takes to map, ablate and remap can significantly reduce costs for the provider and enable the treatment of more patients that need ablation. This is why a fast and efficient system such as the AcQMap system is particularly useful in complex cases; instead of 15–20 minutes, it allows electrophysiologists to remap areas within only 1–3 minutes, thereby reducing the overall time needed per patient significantly. The use of this new innovative technology can further cut costs by simplifying this procedure. Predictable procedure durations also help to expedite procedural wait times and prevent long lab turnaround and lab under-utilization, which in turn, also saves costs.

Mean procedure times of about one hour possible

With new technologies based on non-contact charge-density mapping, formerly very time-consuming procedures can be performed much faster. For example, post AF ablations of atrial tachycardia can now be performed with a mean procedure time of 56.4 ± 12.1 minutes with the AcQMap® system.8 The Real-World All-Comers DISCOVER Registry showed an average total time to diagnosis and first ablation of 8 minutes using the SuperMapTM mode of the system, which allows full-chamber, multi-rhythm mapping of stable rhythms. A study from Belgium highlighted that mapping with the AcQMap system significantly reduced total complex procedure times by 75% to 86% compared to prior studies.8

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Minimizing the need for further interventions

Of course, a treatment should not only be fast, but also effective to avoid AF recurrence and thereby minimize the need for further interventions. A prospective, single-arm study looked at patients with persistent AF in whom the pulmonary veins were isolated and non-pulmonary vein targets were identified with the AcQMap system and eliminated. After 12 months, single procedure freedom from AF on or off antiarrhythmic drugs was 72.5%, and after 1 or 2 procedures, freedom from AF was 93.2%.9

 

The same study indicated that targeting several sites during one procedure can increase the overall success rate. When at least 2 of 3 pattern types were ablated during a procedure, the likelihood of a sinus rhythm at 12 months was 2.8 times higher and when 3 to 4 focal, rotational or irregular patterns were ablated, the likelihood of a sinus rhythm after 12 months was 9.4 times higher.1,2

Shorter procedure times and higher success rates mean less general anaesthesia (GA) and greater quality of life for patients, thereby further reducing costs and countering potential worries of patients, who might be more concerned about procedures requiring GA.

To supply electrophysiologists with the latest technology for the aforementioned map-ablate-remap strategies, Acutus Medical and BIOTRONIK have joined forces. Together, the two companies deliver an array of novel technologies – among them are innovative non-contact mapping techniques, automated pattern recognition and optimized workflows. This allows physicians to quickly map, ablate and remap, resulting in rapid visualization, detection and ablation of any atrial arrhythmia.

Sources

  1. Raatikainen MJP et al. A Decade of Information on the Use of Cardiac Implantable Electronic Devices and Interventional Electrophysiological Procedures in theEuropean Society of Cardiology Countries: 2017 Report from the European Heart Rhythm Association. Europace (2017)19, ii1–ii90.
  2. Chang AY et al. Evaluating the Cost-effectiveness of Catheter Ablation of Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2014 Nov; 3(3): 177–183.
  3. Lee W et al. Direct treatment cost of atrial fibrillation in the elderly American population: a Medicare perspective. J Med Econ. 2008;11:281–98.
  4. Sullivan E et al. Washington DC, US: Avalere Health; 2010. Health services utilization and medical costs among Medicare atrial fibrillation patients.
  5. Wesley C. Change and Challenge: Understanding the Finances of the Electrophysiology Lab. EPLabDigest. 2019;19(10).
    www.eplabdigest.com/change-and-challenge-understanding-finances-electrophysiology-lab.
  6. Kertes PJ et al. Cost effectiveness of radiofrequency catheter ablation in the treatment of symptomatic supraventricular tachyarrhythmias. Aust N Z J Med. 1993;23(4):433-6.doi: 10.1111/j.1445-5994.1993.tb01458.x.
  7. Stern S. Electrocardiogram: still the cardiologist's best friend. Circulation. 2006;113(19):e753-e756. doi:10.1161/CIRCULATIONAHA.106.623934.
  8. Ramak R et al. Novel noncontact charge density map in the setting of post-atrial fibrillation atrial tachycardias: first experience with the Acutus SuperMap Algorithm. JICE. 2020. doi.org/10.1007/s10840-020-00808-9.
  9. Willems S et al. Targeting Nonpulmonary Vein Sources in Persistent Atrial Fibrillation Identified by Noncontact Charge Density Mapping: UNCOVER AF Trial. Circ Arrhythm Electrophysiol. 2019;12 (7):1-12.

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