Western Atrial Fibrillation Symposium

Discussing Advances in Treatment, Digital Health, and Ongoing Research With Nassir Marrouche, MD

Tell us about the origin of the Western AFib Symposium and how it started.

I came from the Cleveland Clinic, where we had started an AFib meeting in 2002. We had great success with that meeting, and I saw the need to focus on this evolving, growing disease. Back then, we knew early on that with the emergence of ablation to treat AFib, that this disease deserved its own meeting.

Beyond just procedures, there is so much more to treatment of this disease. So, I started this concept with 30 speakers at the first meeting in Park City. Fifteen years later, it has grown to be a global, state-of-the-art meeting. In fact, I think the biggest test for the Western AFib was the pandemic. In 15 years, we have never missed a beat. We were in-person in both 2020 and 2021, with 180 attendees in 2020.

The week after Western AFib 2020, the American College of Cardiology’s scientific sessions (ACC.20) were canceled. In 2021, things opened back up and then closed again. We conducted our meeting, which was very successful. It was a record success in partnerships and people’s interest in the meeting. Everyone involved in this disease became part of it and spent 3 days in Park City to talk about the business, science, and education of AFib. So, we went from about 30 people at the first meeting to achieving global reach on AFib management.

Western AFib celebrated its 15th anniversary this year. The meeting has long brought together participants from all aspects of the global AFib community to address the disease from multiple perspectives. How does collaborative discussion and global information sharing among experts from diverse areas improve AFib research and management?

It is from being a researcher in AFib; I have been researching this disease since 1993. I did my PhD work in Heidelberg, Germany, researching potassium channels. We learned soon after, especially when we started doing ablations and going into the heart with catheters, that you cannot look at the disease from one angle. This is a major component of the Western AFib Symposium. If you look at the sessions and the way they are put together, it really tackles this issue. You cannot look at AFib from the point of view of only the ablationist, the traditional noninterventionist, or from the nursing perspective. All the teams who manage AFib need to be talking and knowing what each of them do.

That is why if you look at the sessions of the Western AFib, you never see a session dedicated to only one topic in AFib. It is a mix. So, you have a session where the basic scientist is talking, then the imager, then the ablationist, then the nurse, and then a patient. Then we talk about bleeding in AFib, antiarrhythmic drugs for AFib, and magnetic resonance imaging (MRI) in AFib. This is how our sessions have always been. I have been told, “I am doing a session at Western AFib, and the presenter after me is discussing outcomes in AFib, but my specialty is in cellular electrophysiology (EP).” That was a critique I received 15 years ago. After a few years, I never heard it anymore, because people started loving this format. Why? Because when people are sitting in sessions, they are learning from everyone. That is what led to our success.

That is why if you go to Western AFib, you will see basic scientists, ablationists, nurses, and more all in the same session. They never leave to go ski, because they stay there for the next lecture in the schedule.

This explains why AFib should be managed from a multidisciplinary approach and not only one angle. Western AFib teaches you to look at this disease from multiple angles.

Digital health, artificial intelligence (AI), and its applications in EP have grown rapidly in recent years. Screening for AFib is an important part of clinical practice, and novel approaches leveraging AI and machine learning have the potential to significantly improve patient care and clinical outcomes. What challenges exist in the adoption of digital health technologies and AI into clinical practice? What can you tell us about the potential future applications for machine learning in the detection and management of AFib?

My history with digital health has been since 2008-2009, around the time that the Apple iPhone came out, so I became interested in this early on. From there, it has grown into digital health and biometrics, first with our team in Utah and now expanding this reach at Tulane.

There is no way we can live without AI and digital health—it is impossible. In the last 10 years, we have realized that the major challenge we have to deal with in implementing digital health into medicine is physician burnout. Consumers are on board, tech is on board, but we are not on board. Who is paying them? Are they liable? All this information is coming in all the time. I recently wrote about this in an article on consumer-tech-provider codoctoring in the digital age.¹ I have probably 1800 patients I deal with regularly in my clinic and active follow-ups. I am giving every one of them, or they come to me with, a digital component of the watch to track themselves, especially in EP. There is no way I can deal with those patients without an AI platform that processes and gives me what I need. I cannot hire enough nurses to track those patients.

So, AI is coming. It is already here, but we are not allowing it as physicians because we are scared. What is next? Is it going to take us over? Is it going to replace us? How will we get paid? Will we get reimbursed? What is the liability issue? I think these are components we are solving as we speak.

But AI is happening. Kodak and Sony are the best examples. Sony had the best camera ever, right? When Kodak failed, Sony came into the picture and we said, “ Sony is the future!” Now, the iPhone is the only camera that people use. It is the same thing here. If we do not start adapting as physicians to AI, it will be replaced by somebody else.

This is from the business and administrative perspective. But more importantly, the thing that perplexes me the most is we see this as something bad or challenging happening to us. I see it as a positive thing for humanity.

My daughter, who is 10 years old, has a FitBit and she is going to live healthier as a result. She comes to me every day and says, “I did my 10,000 steps today!” She uses my Apple Watch to look at the electrocardiogram (ECG). It took me a year to finish the ECG course in medical school. Now, tell that person in 8 years when she is in college that she has to go see a physician to get an ECG. I challenge you to tell her that. No, she is going to access her ECG using her smartphone. Hopefully she would never need treatment such as an ablation or blood thinners. She could then go to Amazon and click on blood thinners and choose one. Yes, that is happening.

All of us are trying. I think there is some question about the ethical part of it and how we can allow a machine to do this. However, machines are already treating us today. The monitor that is implanted into your chest to monitor your premature ventricular contractions (PVCs) and extra beats is a machine. It is using AI to predict if this is a PVC. The Carto mapping system (Biosense Webster, Inc) is a machine—I follow the red, yellow, and purple colors on the map to ablate the arrhythmia based on that information. It is nothing different with machines predicting what drug is needed.

It is just a matter of time when you will be hearing about it more and see it become implemented into standard of care with digital treatment, which is what we are actively working on now. Stop talking predictive models, that is over—we have enough data. I want to be able to tell a patient that, based on the data from their smartwatch, not to take blood thinners today, they are healthy. Or, if needed, take an aspirin today.

That is what we are working on from an AFib perspective; for example, predictive recurrence of AFib after treatments to give patients, based on a digital treatment or AI model, a better drug or something to help them, vs the other standard of care. So, that is what we need to establish in our society and community. That is what we are working on now, as we speak.

New findings from DECAAF II do not support the use of MRI-guided fibrosis ablation for the treatment of persistent AFib.² Can you discuss the role of atrial fibrosis in the pathophysiology of AFib and how our understanding of atrial fibrosis progression has evolved?

This is my third multicenter trial. The number one lesson we learn from clinical trials is that you have to be ready to see results the way they are. You ask a question. I provided delayed enhancement MRI images to 44 key opinion leaders—the best ablationists in the world—and told them to look at the fibrosis and treat those patients with ablation. The other arm performed pulmonary vein isolation only, which is the standard of care. And that is why I put the intention to treat—not to bias. The reason I posed this question is because DECAAF I, which we published in the Journal of the American Medical Association (JAMA) in 2014,³ showed that whatever you do, if there is advanced fibrosis, you are failing. So, in the conclusion in JAMA, I wrote not to ablate advanced fibrosis. We asked the question, collected images, let people ablate the way they want, received this as the outcome, and that was what we reported.

The details of this other paper are coming; there are 22 papers from DECAAF II coming in the next 6 months. This was the first study that I objectively controlled what was done, because I showed exactly the ablation that was done and how the fibrosis formed on MRI 3 months later. We looked at the Carto maps of the patients and saw the areas that were ablated. Just as importantly, we collected every single Carto map that was downloaded as part of the study and looked at lesion formation. It is a beautiful study and the data is amazing. We have 1600 MRIs or more, and 800,000 ECG strips.

Going back to these findings, which do not support the use of MRI-guided fibrosis ablation, the way we provided the data, only 5%-6% of them ablated the fibrosis per the protocol. What we learned is that fibrosis progression is a problem.

If you look at the data on advanced fibrosis in the paper, you will see that more than 20% of patients stroke more postprocedure, more regions need to be ablated, and there is more AFib recurrence. However, the patients with less fibrosis do much better—early intervention is important. But we have to deal with fibrosis seen on MRI in a different way rather than ablation. Ablation does not help them—maybe some groups—but that is not the message here. The message is that MRI-guided fibrosis ablation for AFib does not help improve outcome more than 45%. Rather, it tells us not to ablate this patient—your success rate is only 30%-40%. The more fibrosis, the worse the outcome—that is what we proved here again. Finding that solution to deal with this fibrosis beyond ablation in this population and doing it in a 45- to 60-minute PVI procedure instead of more complex fibrosis ablation with lines and appendage closure. You get the same outcome. This is the first and largest persistent AFib trial to study ablation. In addition, this is the biggest cardiac MR trial ever, which is good for all the EPs and imagers who want to participate in managing MRI scans and their complexity. I am so proud of the 44 global sites who participated and all of the team who finished this trial during a pandemic. There is no such thing as a negative vs positive trial, by the way. We learned a lot. And now, I think I have saved the EP labs at least an hour or hour and a half of ablation time by just doing PVI in persistent AFib, which is a complex patient population. We are expecting a 50%-70% outcome based on what you see. We learned an important message about fibrosis in this trial—that we need to deal with it in a different way other than ablation. You cannot burn it to fix it, you need to do something else. Can we stop it before it happens? Maybe, but not now.

Western AFib remains a favorite among professionals not only for its state-of-the-art science, but also for its incredible location in Park City as well as its intimate conference setting, allowing opportunities to meet one-on-one with speakers. To what do you attribute the long-standing success and popularity of the meeting?

Anywhere you land and anywhere you go, the meeting experience is made by the people, right? Take the Heart Rhythm conference, for example. If you ask me, where were the last 5 conferences? I do not remember. I only remember the people and the sessions. I can tell you which sessions were great. The people I interact with—that is what makes a meeting for me—the speakers. That is the whole component. The presenters and faculty that we have attracted to this meeting have made it a success. It is simple.

The location helps as well. But if you look at how many of the people who come just to ski and then see the number of people sitting in the room during sessions, you know that is not the case. In fact, the reason why I kept the agenda from 7 AM to 7 PM is to show people this is not a “ski” meeting—it is a scientific meeting. It is really the speakers and topics that people are attracted to. Attendees come to interact, discover, and learn. So, it is all about the people who come year after year and give these great lectures that has made this meeting a success.

Disclosures: Dr Marrouche has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. He reports consulting fees from Biosense Webster, Inc, as well as research grants or contracts to his institution from Biosense Webster, Inc. He also reports that he is a board member of the Heart Rhythm Society and program chair of the Western AFib Symposium.

Join us at the 16th Annual Western AFib Symposium, taking place February 24-25, 2023!

Editor’s Note: The transcripts have been edited for clarity and length.

References

1. Dagher L, Marrouche NF. Consumer-tech-provider co-doctoring in the digital age: a neglected TRIAD. Heart Rhythm. 2021;18(4):P499-500. doi:10.1016/j.hrthm.2020.10.007

2. Marrouche NF, Wilber D, Hindricks G, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. 2014;311(5):498-506. doi:10.1001/jama.2014.3

3. Marrouche NF, Wazni O, McGann C, et al. Effect of MRI-guided fibrosis ablation vs conventional catheter ablation on atrial arrhythmia recurrence in patients with persistent atrial fibrillation: the DECAAF II randomized clinical trial. JAMA. 2022;327(23):2296-2305. doi:10.1001/jama.2022.8831