PracticeUpdate Cardiology June 2019

EXPERT OPINION 15

patients, an invasive approach to ablate and try to restore sinus rhythm. One needs to be selective with a particular patient. One needs to sit down with a patient, talk about pros and cons, complications, and so on, and if the patient is agreeable after all of that, I certainly would be in favor of an ablation approach. Dr.Shah: That is fascinating and, fromwhere I’m sitting, it seems, Doug, the last year and a half, we’ve been talking about the management of defibrillation, but the year and a half or two years before that, we were talking about anti- coagulation because that entire aspect of management changed. One lingering question I haveabout anticoagulation is, is thereapatient for whom you would not anticoagulate? Dr. Zipes: Yes, one could make a case for a young individual with absolutely no risk factors having episodes, short-lived, of par- oxysmal atrial fib and not anticoagulate that individual. We have algorithms that tell us whether the patient really is at stroke risk and should be anticoagulated. My bias is to be far more liberal with anticoagulation with the new drugs than I was years ago when I had to use warfarin and get protons, and getting a patient to take the warfarin on a regular schedule and remain in that

restore sinus rhythm, and as I said, ideally, 65% to 75% success rate. Some patients need a second, or rarely, a third proce- dure, and it’s often dependent on the skill of the electrophysiologist. So, one really wants to go to a high-volume center that does a lot of the atrial fib ablation. There’s no question, restoration of sinus rhythm is preferable. I’m well aware, as we all are, of studies showing rate control versus rhythm control, no difference in outcome. Those are complicated by a lot of issues. Ideally, sinus rhythm is preferable, and the most successful approach really is ablation. Now, the recent study headed by Doug Packer, the CABANA trial, was a prospective randomized trial, and they demonstrated that those individuals who went to ablation rather than medical therapy, if you do an on-drug analysis, statistically, they did better with sinus rhythm. If you do an intention-to- treat analysis, there really was no difference. The recent data show an improvement in lifestyle and how these individuals feel, and that’s very important. So, even if we don’t make you live longer, if we make you live better, that really is a major advance. And that’s basically what the recent data show with the CABANA trial. So, I am an enthusiast for, in selected

very isolated area of adequate anticoagu- lation was a very difficult challenge. It was better than not having it for the patient at stroke risk, but now it really has become so much more easy to do. And now, with reversible agents that are coming online, it makes it even better. Dr. Shah: That makes a lot of sense. Dr.Zipes: And the technology for ablationmap- ping will get even better. And in the future, what I would like to see, which is just starting for some ventricular arrhythmias, is a non-in- vasive electrophysiologic study to identify areas to be ablated and then a non-invasive ablation approach using radiation or some other form of energy without even opening the chest or putting a catheter in a groin. Dr. Shah: That would be fascinating. Dr. Zipes: And that will happen.

Dr. Shah is Executive Publisher, Online Content at Elsevier.

Go to www.practiceupdate.com/c/81073 to watch this interview with Dr. Zipes.

VOL. 4 • NO. 2 • 2019