Western Atrial Fibrillation Symposium

Discussion With Deepak Bhatt, MD, MPH, and Nassir Marrouche, MD

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Deepak L. Bhatt, MD, MPH, Editor-in-Chief of the Journal of Invasive Cardiology, talks with Nassir Marrouche, MD, Director of the Western Atrial Fibrillation (AFib) Symposium, about this premier educational event, including opportunities for interventional cardiologists. The 17th annual Western AFib Symposium takes place February 23-24, 2024, in Park City, Utah. For more information, please visit westernaf.com.

Deepak L. Bhatt, MD, MPH: Hello, I am Deepak Bhatt, Editor-in-Chief of the Journal of Invasive Cardiology. It is a pleasure to have here with me Dr Nassir Marrouche, who is the director of the Western AFib Symposium. He is going to talk with us about the symposium and why it is important not just to electrophysiologists, but to interventional cardiologists as well. Nassir, it is great to see you. It has been a while since we were at Cleveland Clinic together. I am happy to see all you have done since that time, and it is great to be with you today.

Nassir Marrouche, MD: Thank you, Deepak. It is a great pleasure. I am proud to see you leading a major institution at Mount Sinai in New York City. Growing up with you at the Cleveland Clinic, I could not be prouder of your career. Thank you for inviting me today to talk about Western AFib.

This AFib-focused meeting has been going strong for more than 16 years. We started with 70 people and have grown to more than 650 attendees every year. With the advances that have been made recently in invasive AFib treatment, the meeting is appealing beyond cardiac electrophysiology (EP) itself and of interest to those in structural heart disease and interventional cardiology, with discussions on septal closure devices and left atrial appendage closure devices as well as management of cardiac device patients with AFib and an indication for blood thinners, and beyond. About a third of the meeting is focused on these topics that appeal to interventional cardiologists, so we hope they will join us next year at Western AFib in Park City.

Bhatt: That is terrific. As you may know, JIC is not specific to only interventional cardiology. We cover invasive cardiology topics quite broadly, so a big chunk of that is interventional cardiology, but EP is something that we cover as well. I think a number of our readers would be interested in your meeting. In terms of some of the topics that will be covered there, you mentioned left atrial appendage occlusion. That is certainly something that some interventional cardiologists are doing in some cases collaboratively, even in the procedural suite with electrophysiologists, and in some cases on their own. So, I think there is some heterogeneity of practice. I have found that in doing those sorts of procedures together, there is a lot one can learn from the other. What is it in general that you are seeing around the country in terms of who is doing left atrial appendage occlusions?

Marrouche: It depends on the institution and collaboration between the teams. Electrophysiologists are tending to see more and more AFib patients and people who need ablation, so we are in the left atrium most of the time—it makes up about 60% of our day. If you perform ablations only, you are in the left atrium maybe 80% of the time. We are then following up with these patients, so we are seeing more of these procedures. Since we are now acquainted with these devices, we are implanting them more and have a higher threshold for using them to avoid bleeding, which is a devastating complication of blood thinners. Approximately 15%-20% of procedures per month are related to closure devices in our labs.

In our institution, our interventional cardiology colleagues perform structural heart procedures. They see their own dedicated subset of patients in the clinic, especially patients with coronary artery disease and AFib who have an indication to blood thinners. Therefore, the interventional cardiologists are fixing this themselves and getting more cases. It is not specified, and I am seeing this more in the interventional arena that it is not focused only on structural heart disease anymore—it is becoming more global and people in interventional cardiology are getting more structurally acquainted. My colleagues at Tulane have been working with us as well. At my institution, I would estimate it is 80/20 in terms of electrophysiologists performing the closure devices versus interventional cardiologists. At other institutions, it may be 50/50. So, it depends on the relationship and who is seeing more of these patients.

Bhatt: I agree with those observations. What sort of things are new and interesting as far as AFib ablation? Are you excited about pulsed field ablation? What things are exciting you and what will be covered at the Western AFib meeting?

Marrouche: Everyone is talking about pulsed field ablation. In the last 2-3 years, the data has been coming out on efficiency and whether it is a faster procedure. We are still waiting for the long-term data. As you know, recent data showed that the success rate was similar to RF, but it is a faster procedure. We talk a lot about electroporation and the excitement around initial experience. We are learning a lot about dosing, where to ablate, how to ablate, how long to stay, and collateral damage. The field is beginning to adopt this.

But as important as electroporation is the long-term data on ablations. We have a couple studies that we are presenting as late-breakers at the ESC Congress 2023. We are using artificial intelligence (AI) in our trials to guide us to AFib treatment. For example, in the DECAAF-II sub-analysis, which will hopefully be coming out soon, we changed the whole trial design to using an AI model to predict the patients who fare best based on age and other factors. So, we are learning a lot as we go. We have a couple of trials that we will be talking about at Western AFib related to heart failure and AFib using drugs and tools and so forth. This is a new thing coming to our AFib treatment, although you have been dealing with this for a while.

Regarding digital health in medicine, we have a lot of devices being used in EP. It started with EP with AFib detection and pulse checks. This has been scaled into our practices with integration of AFib detection and monitoring. I am always using these prediction methods in practice. About 30% of Western AFib is dedicated to covering these areas. We will have major players with us in that meeting from Samsung to Apple to Google, as well as newcomers to help us with understanding the use of AI from regulation to HIPAA to FDA approvals to outcome studies. This will all be discussed during the 2 and a half days of Western AFib in Park City.

The beauty about the Western AFib agenda, which we are proud of, is that it is always updated within 3-4 months before the meeting to the very latest information. We do not build the program a year in advance. Therefore, you always have the latest data. In 2024, you will see a lot of information on digital AI integrated into the program as well.

Bhatt: That is terrific. There is no question digital health in general is booming. It has finally reached a mature stage across medicine, but EP is really at the vanguard of that, with all sorts of things going on. Of course, the lay public is very interested in this with their various smartwatches and detection of arrhythmias, sometimes with pretty good accuracy and sometimes maybe not as much. Machine learning and AI algorithms in EP seem to also be really booming. Even with the plain old electrocardiogram, it is quite remarkable to see some of the machine learning that is going on that is finding all sorts of signals beneath the surface that the naked human eye cannot detect. So, it is really a remarkable series of development and EP is quite central to that, but also with applications to other areas such as interventional cardiology and cardiology in medicine more broadly. Before closing, do you have any final thoughts you want to leave the audience with on why they should attend the Western AFib Symposium?

Marrouche: I have always called Western AFib a “family” meeting. It is a family of physicians, cardiologists, primary care providers, and more. For the last 7 years, we have kept lectures to 10 minutes each, with a 20-minute discussion at the end of each session. But probably the best part about this meeting is that everyone is there. It is a ski town, as you know, but with all lectures and faculty in one room, people never leave. It is one big room filled with over 600 people. Hopefully we can have you, Deepak, join us in Park City as well! It is wonderful to have everyone in the same place. It has also been in the same location and hotel for the last 16 years. We hope to see all of our colleagues from around the world at Western AFib. 

Bhatt: Nassir, congratulations on this symposium. I certainly encourage folks that are listening to attend. It seems like it is a great educational experience and there is so much going on in EP with ramifications for interventional cardiology and also general cardiology. So, thanks so much for joining me.

Marrouche: Thank you my friend and thank you for hosting me.

The transcripts have been edited for clarity and length.

Join us for the 17^th annual Western AFib Symposium, taking place February 23-24, 2024, in Park City, Utah! For more information, please visit westernaf.com.