“It's a tug of war. We expected more but with one thing and another, we were tryin’ to outdo each other in a tug of war,” sang Paul McCartney. Similar to McCartney’s hit Tug of War were the data presented at last week’s Boston Atrial Fibrillation Symposium (BAFS) and the Society for Cardiovascular Angiography and Interventions (SCAI) meeting in Philadelphia.
At both conferences, cardiovascular specialists talked about various interventional and ablation procedures, anticoagulant therapy and practice guidelines, as the industry continued to try and understand whether certain procedures or treatments produce better outcomes or whether it depends on preference.
For instance, last week at BAFS, Dr. James R. Edgerton, a cardiothoracic surgeon, argued that creating a partnership between electrophysiologists and surgeons during ablation procedures can help improve AF outcomes. While he offered that this system could leave the two specialties butting heads due to reimbursement and referral issues, he said that both surgeons and EPs excel at different techniques and working in concert could help.
Additionally from BAFS, Dr. Jeffrey Weitz of McMaster University offered that the future of AF will feature novel anticoagulants including dabigatran, rivaroxaban, apixaban and edoxaban, which may outshine warfarin. While the new anticoagulants may alleviate the worries associated with warfarin—slow onset of action, genetic variation and food and drug interactions—understanding which patients may be the best candidates for these new anticoagulants remains up in the air.
At SCAI, Dr. Pinak B. Shah, a vascular surgeon from Brigham and Women's Hospital, put forth a 12-step program for what he called 'femoral-aholics,' outlining why most refuse to adopt the radial PCI approach and how they can overcome their "addiction" to femoral access.
Shah said the radial approach leads to better patient comfort and a quicker recovery time when compared with femoral access, even with closure devices. Most importantly, Shah offered that education of staff is key when weighing the options to start a radial program.
Similarly at SCAI, while Dr. Jennifer Tremmel of Stanford said that the transradial approach is a viable option, beginning transradialists should proceed with caution and start with easy cases such as younger, taller and diagnostic-only patients. In addition, she said that some cases for beginners are more difficult and should be avoided, such as certain dialysis patients, those with a failed Allen's test and hemodynamically unstable patients.
"In a time to come, in a time to come we will be dancing to the beat played on a different drum," McCartney sang. Will the transradial approach replace the femoral approach as the optimal technique for vascular access or will dabigatran become a first-line treatment over warfarin? Or will these decisions be left to preference and leave physicians in a tug of war?