Tech breakthroughs, new policies help cardiologists perform more concomitant EP procedures
As electrophysiologists increasingly look to streamline care for atrial fibrillation (AFib) patients, concomitant procedures that combine catheter ablation with left atrial appendage occlusion (LAAO) are gaining traction. Cardiovascular Business spoke with Devi Nair, MD, director of electrophysiology (EP) and research at St. Bernards Medical Center and the Arrhythmia Research Group, who said this is a developing trend in EP driven by reimbursement changes and advances in device technology.
"We got the diagnosis-related group (DRG) code for concomitant procedures last year, and there's definitely been a pretty steady increase in the adoption of concomitant procedures," Nair explained. This created a clearer reimbursement pathway for hospitals performing combined therapies.
At the same time, new clinical data are reshaping how physicians think about stroke prevention in AFib. Nair pointed to results from the CHAMPION-AF trial presented at the annual meetings of the American College of Cardiology and the Heart Rhythm Society. The study showed the Watchman FLX device was noninferior to oral anticoagulation for stroke prevention in indicated patients.
“What it showed is that Watchman devices are a reasonable alternative to anticoagulation if a patient wants the therapy and they have an option to choose,” she said. “We only have three-year data, but I think it comes down to shared decision making.”
Click here to learn more about CHAMPION-AF.
Patient selection is key
Nair said patient selection remains critical when considering concomitant therapy. For patients with low stroke risk scores, she often prefers catheter ablation alone with follow-up monitoring before discontinuing anticoagulation therapy.
“If a patient has a low CHADS-VA score, like 0, 1 or 2, I’m comfortable doing just the ablation and monitoring them for a year,” she explained. “If they don’t have recurrence, then we can take them off their anticoagulation.”
However, patients with higher stroke risk scores who require both rhythm control and long-term stroke prevention are the best candidates for a combined procedure.
“If a patient has a higher CHADS VA score and they need stroke prevention and rhythm control, then that patient is an ideal candidate for me,” Nair said. “There have been multiple centers that have shown data that this is safe. We can do this safely and we can do it effectively.”
New LAAO technologies in trials
Nair also highlighted several new technologies designed to simplify concomitant procedures and improve procedural outcomes. She pointed to next-generation appendage closure devices currently in development, including the Watchman Elite and the Amulet 360.
“These are all-new devices that are going be more conformable and give us better seal,” she explained, which will enable better outcomes, since the size and shape of the LAA can vary widely between patients.
Imaging technology may also play a major role in expanding adoption. Currently, many operators rely on transesophageal echocardiography (TEE) guidance for LAAO procedures. TEE requires an echocardiographer to operate the probe and it needs to be used under general anesthesia.
Newer ICE technology has image quality on the same level as TEE, and 4D ICE could be used to guide LAA closures without the need for a separate echocardiographer and general anesthesia. However, Nair said it remains less common because it often requires advancing the ICE catheter into the left atrium, which makes many operators uncomfortable.
However, Nair recently presented first-in-human data on her experience with a next-generation ICE catheter developed by Siemens Healthineers. She said the new catheter features more than 1,700 imaging elements and a 120-by-120-degree field of view, enabling physicians to image the procedure entirely from the right atrium without crossing into the left side of the heart.
While clinical experience with the catheter remains limited, Nair said the early results have been encouraging.
"The future is bright," she said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]