FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016
WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF A STANDARD APPROACH TO ABLATION IN PAF?
00:12 – Ablation for PAF has been something that has evolved a lot over the past decade and a half, let’s say. Like any new technique, when it started, it used to be this highly complicated procedure that took forever, that took literally the whole day, you would spend the whole day in your lab. You wouldn’t know how the procedure would start, you definitely wouldn’t know how it would end. And I think as with any procedure, of course you’d like to avoid all this, you’d like to have a very predictable procedure. The intuitive advantage is it goes fast, that’s what everybody thinks about. And when you say standardise, people say, “How? Let’s make it faster.” We worked a lot on this, we’ve managed to successfully integrate technology both image-integration technology and catheter technology in our workflows, and we’ve succeeded in building workflows that allows to predict our procedure times to the minute. Our standard deviation of procedural time is down to four minutes on a total procedure time of a little bit over an hour. Now the true benefit is actually not this time gain, it’s nice, it’s good to have. But as any manufacturing plant can tell you, the true benefit of standardisation is you become more efficient. You become more efficient because anything that deviates from your normal workflow, provided you know what is supposed to happen, anything that deviates, stands out, you will notice immediately if anything’s off. So we believe, we think, I strongly believe, that standardisation allows me greater efficacy and greater safety. The fact that it’s fastest is really nice to have but it’s a side benefit. The true benefit and the true advantage, is enhance the efficacy and enhance safety.
WHEN SHOULD ABLATION BE CONSIDERED IN PREMATURE VENTRICULAR CONTRACTIONS?
02:00 – PVCs, premature ventricular contractions, are an interesting phenomenon. And for the longest time I guess most people wouldn’t really be able to say whether it’s a phenomenon or a symptom or something that needs to be treated, yes or no. Actually I’d argue we still don’t know for sure whether we need to treat them. But what you can point out is that from historical data, people started studying whether it made sense to, for example, treat these phenomena with drugs, and in particular, with the CAST trial we learned that in the setting of acute post-infarction patients, giving drugs to these patients to supress their PVCs is actually a really bad idea. It’s a landmark trial, it’s a landmark trial for evidence-based medicine in general. It showed us that usual conventional wisdom is not always right, that you need to do randomised trials. And it changed the field. Because of that, for example, specifically for PVCs, people still feel like, “No, it’s a bad idea to treat them. Look at the CAST trial. We’re killing patients.” That’s not necessarily true for all these patients that have PVCs, that are not in the post-infarct setting. Actually there’s good data published in 2014, 2015, meta analyses, studies for example, the cardiovascular health study, population study showing that PVCs actually do predict heart failure. It’s not necessarily benign, it’s not necessarily a phenomenon that you can ignore. It doesn’t prove you need to treat them but it does prove they are important. And then we start talking about treating them of course, then you have the option of giving drugs to these patients. But you also have the option of doing an intervention, of doing an ablation. And as with any technology-driven intervention, initially people are wary, they’re cautious. It’s new, it’s potentially dangerous, may lead to complications, and there’s always drugs. And we can give drugs and we know in which patients we shouldn’t and we know in which patients it’s probably reasonably safe to give drugs. Now the thing about any technological intervention is, it grows better over time. It evolves. Technology evolves, experience evolves. It’s not true for drugs. Drugs, they are what they are. Nothing on the planet will ever make sotalol better. It’s the drug we have, we know the data and it’s going to be like that until someone comes up with a new drug, and that doesn’t happen often. But for technology it’s different. We have ablation and every month, I’d argue, we get better at it because we gain more experience and because technology improves. So I think we’re getting to the point where at least from a study point of view, we need to reconsider this notion where people say PVCs shouldn’t be treated. I’m not so sure about that. I can approve there’s a causal link between PVCs and heart failure, but I can show there is at least a correlation. And we can show that we have a highly efficient and incredibly safe technique to treat these PVCs which is, I think, a worthwhile topic for study.