Brief Summary
This podcast episode of "This Week in Cardiology" covers a range of topics including listener feedback on previous discussions, significant updates in pulse field ablation (PFA) for atrial fibrillation (AFib), alarming obesity trends in the U.S., and an analysis of a trial involving an AI-enhanced stethoscope. The episode emphasizes the importance of vigilance in adopting new technologies like PFA, understanding the underlying causes of AFib, and addressing the growing obesity crisis. It also highlights the necessity of rigorous testing for new diagnostic tools to ensure their effectiveness in real-world clinical settings.
- Listener feedback on TE vs no TE before ablation, procedural volume with TAVI and Mitro trans catheter edgetoedge procedures, and LG in older athletes.
- PFA pulsefield ablation for Aphib updates and concerns.
- Obesity trends in US.
- AI enhanced diagnostic tool in the office.
Introduction
John Mandola from the heart.org Medscape Cardiology introduces the topics for this week's podcast, which include listener feedback, news in PFA for AFib ablation, obesity numbers, and a trial studying an AI-enhanced diagnostic tool. He also mentions his recent lecture at the British Cardiovascular Intervention Society meeting in London, where he discussed interventional trials and the wasteful aspects of AF ablation.
Listener Feedback
The host shares feedback from Professor Yakim Erlick regarding ICE versus TEE coverage before cryoballoon AF ablation. Erlick's research suggests that using a risk score can help avoid TEE, with both TEE and no TEE (if the risk score is negative) resulting in a high chance of no post-procedural strokes. Dr. Anthony Pearson commented on the lack of adequate training for doctors in performing TEE, leading to interpretation errors. Dr. Stefan Osbach noted that the ICE versus TEE trial demonstrated that ICE increases safety by reducing major bleeding events related to the transeptal puncture. The host admits that his view of ICE has changed and he likes the reassures it gives him during the transpal.
PFA Pulse Field Ablation for AFib
The host discusses the Beat Parox AF trial, which compared PFA to RF ablation in patients with paroxysmal AF. The trial found no significant difference in the primary endpoint of single-procedure success at one year between the PFA and RF groups. PFA was faster, but not better in terms of efficacy or common safety measures. The host notes that the lack of difference in adverse events is deceptive, as PFA likely reduces terrible events like death from atrial esophageal fistula or permanent phrenic nerve injury. He suggests that the trial represents the hardest test for PFA because the RF control arm was performed in some of the best labs in the world. The host also expresses concern that research has been more interested in selling ablation devices than discovering causes of AF.
PFA Safety Concerns
The host discusses a paper from the Hamburg CCB group, which reported life-threatening delayed myocardial ischemia and malignant arrhythmias occurring after PFA ablation of atrial fibrillation. The study found that life-threatening adverse events occurred in 0.16% of patients. Nine of the 11 patients had PFA ablation outside just the PVI. Two patients had sudden cardiac death three and 22 days after PFA. The author speculated on this novel and scary report where major arrhythmic events occurred in minutes or days after PFA. The host also mentions a well-circulated MA adverse event of a death from AE fistula following AF ablation from a PFA system. He emphasizes the need for better recognition, reporting, and understanding of underlying mechanisms to improve PFA safety.
Obesity Trends
The host reports on an update from JAMA on US state-level prevalence of adult obesity by race and ethnicity. In 1990, 19% of US adults had obesity, while in 2022, 42% had obesity. The authors forecasted that 47% will have obesity in 2035. There are very large racial ethnic disparities, especially among women. The highest rates of obesity are in the Midwest and southern parts of the US. Peak obesity occurs in middle age 45 to 64 years. The biggest increases since 1990 are among women under age 35. The host expresses concern that half of US adults are expected to be obese in the coming years, calling it a public health catastrophe.
AI-Enhanced Stethoscope Trial
The host discusses a cluster randomized trial of primary practices in the UK that studied the use of an AI stethoscope. The trial randomized 205 primary care practices covering 1.5 million patients. The primary endpoint of new heart failure diagnosis and secondary endpoints of AFib and valvular heart disease detection showed no significant difference between the groups. Only 49% of examinations were labeled with patient identifiers for data linkage. By 12 months, 40% of practices had stopped using the device entirely. In an adjusted analysis, the stethoscope crushed it with 2.2 times higher rates of heart failure diagnosis, 3.4 times higher rate of AF diagnosis, and 1.9 higher rate of valvular heart disease diagnosis. The host highlights the difficulty in screening for conditions that have population incidences that are about 1%. He emphasizes that new tools have to work in both idealized conditions and in the setting of the real world.
