EP expert gives overview of the specialty

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The evolution of electrophysiology technology and treatment has exploded over the last few years. Andrea Natale, MD, executive medical director of the Texas Cardiac Arrhythmia Institute in St. David’s Medical Center in Austin, Texas, provided an overview of the field to Cardiovascular Business News.

“When I started, electrophysiology (EP) was a surgical treatment for arrhythmia and only for very few cases,” Natale said. “Most arrhythmias were treated with drugs. Atrial fibrillation, for example, was a neglected arrhythmia, because we didn’t have anything to do for these people except give them drugs. In the last 10 years, we have gained a better understanding of all the underlying problems associated with complex arrhythmias. In addition, the evolution of tools and devices has helped us do a better job to target those areas causing problems.”

There are several areas that have evolved the most, Natale said. One is the ability to treat patients with complex arrhythmias, which include ventricular tachycardia, atrial defibrillation and post-cardiac surgery tachycardia.

A second is the evolution of implantable cardiac devices (ICDs) for heart failure patients. This not only reflects improvements in the technology, but also improvements in the understanding that many more patients than physicians previously thought can benefit from ICDs and that many more patients can benefit from biventricular pacing devices—especially patients with left bundle branch block and wide QRS, Natale said.

An interesting aspect regarding the exploding use of catheter ablation procedures and device-based therapy is that the actual number of patients being treated is low compared to those who could be treated, Natale said. The problem is that referring physicians need to be better educated about EP options for their patients and about patient follow-up care.

Part of the problem, he admitted, is that the evidence doesn’t always support ablative therapy as a first-line treatment option. “For atrial fibrillation, ventricular tachycardia and post-cardiac surgery arrhythmia, ablation is considered only after drug therapy failure,” he said.

For atrial fibrillation, there is increasing evidence from randomized trials that ablation is more effective than trying a second medication after the failure of the first drug. There also is increasing evidence that ablation can be considered as the first-line therapy, but that evidence has not yet been definitively established. “But a change could enter the guidelines within five years,” Natale said.

Regarding ventricular tachycardia, only a few small studies indicate that ablation is better than drugs. “A problem with this patient population is that by the time they come to us, they are full of toxic drugs. They should probably come to us sooner than later,” he said. “But the guidelines do not support an earlier intervention. Studies looking into it are underway.”

For atrial flutter or atrial supraventricular tachycardia, ablation can be the first-line therapy. The evidence suggests that single ablative procedures in these patients are easy and have a high success rate.

Data regarding the cost-effectiveness of ablation versus anti-arrhythmic drug therapy is mostly retrospective, which suggests that ablation is more cost-effective. Prospective studies are ongoing and should be available in a few years.

The key right now is to educate referring physicians and general cardiologist about EP treatment options for patients and to have uniform training of EP physicians, Natale said.

“We want to have the same rates of success in the community hospital setting as we do in our academic centers or in our centers of excellence. We need to train the next generation of EP physicians and we need to develop the technology to make the procedures easier and more reproducible,” he said.