Archive for 2016

CSI 2016 – Focus Left Atrial Appendage Closure

Dr Malik was invited to speak at the Left atrial appendage closure meeting-CSI LAA- in Frankfurt this week. He had produced a summary of the data discussed.

Who should have it?
Guidelines say that it should be for those who cannot take anti-coagulation. However, the largest Trial –PROTECT-AF- was of LAA closure with the watchman device against warfarin. And the Watchman won!
European guidelines suggest that the HASBLED (bleeding) score needs to be considered as well as the stroke risk- assessed by the CHADSVASC score.
US guidelines suggest that the Watchman could be used if the doctor thinks that LAA closure may be beneficial, if the patient is suitable for anticoagulation. The FDA has recently approved the Watchman for use in the USA. On patients suitable for warfarin.
In the UK, the funding is extremely restricted. This is limiting its use, unlike in other parts of Europe.

In the UK, it is estimated that it costs the NHS about £7000, including the device which is about £3500.
It is cost effective, and becomes “dominant” ie cheaper and more effective, after 10 years (if comparing to Warfarin, as warfarin is cheap) or 5 years against NOAC (as these newer drugs are more expensive)

Who decides?
The management of AF rhythm is separate from the management of stroke risk. However, the AF does need assessment, in case it could be cured. It is worth discussing the options at a Multidisciplinary meeting to ensure that is procedure is appropriate.

What is the risk of the procedure?
• In the key trial, PROTECT-AF, the complication rate was 8%.
• In the EWOLUTION European registry of >1000 Watchman , the event rate was 1.5% only. Tamponade, bleeding around the heart was now very rare.
• In the USA registry of 3822 patients, Tamponade was in 1%, and there were 3 deaths (ie 0.1%) and thus the procedural risk is now very low. The procedure took less that 1 hour!
• In the European Amulet study of 1072 patients, there were 3 deaths (0.3%),and 0.5% pericardial effusion.
• In a study of patients who have had intracranial bleed (ICH) and so could not take anticoagulation for AF, there appeared to be a major reduction in bleed and death in a registry comparing LAA closure to medical therapy. There is now a trial staring to look at these very high risk cases.
REMEMBER: If the CHADS VASC score is 4-5, then the ANNUAL stroke risk is 5-10%! Thus doing nothing is not a safer option. If you have bypass surgery, the surgeon would rarely quote a risk of less than 1%, so the risk from LAA closure is not so extreme!.

Technical aspects:
• I do it under general anaesthesia with good quality 3D transoesopgageal echo (TOE).
• Using intracardiac echo (ICE) was discussed. It avoids the general anesthetic, but the imaging is not as good as TOE. Thus I don’t use it.
• Amazing imaging such as fusing the CT image and the TOE image with the Xray was shown. Very nice, BUT not essential- I don’t use it. Having a team member doing a good quality TOE that I can see is much better than trying to to blend all the imaging on screen. I blend it in my head!
• Having the patient well hydrated was discussed. Giving fluids during the procedure might make the LAA a small difference in LAA size.
• 3D printing of the CT scan to see if you could practice the procedure is not essential. It is not going to predict what really happens!
• Types of Devices- Loads!
o Watchman
o Amplatser Cardiac Plug
o Lambre
o Occlutech LAAO
o Surgical-percutanous- Lariat
• Post procedure drugs
o No consensus on if NOAC/warfarin needed after LAA occlusion, or for how long

If you cant take anti-coagulation, you should really be considered for LAA closure. If you can, then consider NOAC like apixaban or rivaroxaban, or warfarin. A great meeting, and one that reassures me that the UK is behind the curve, and we should be offering LAA closure for more people than we are allowed to. I look forwards to doing my next live case at the next international meeting.

Dr Malik: TCT 2016 Conference

Dr Malik, performed two live cases for the international TCT cardiology meeting this week, with Dr Justinimage1 Davies.

They demonstrated the use of advanced imaging and physiology techniques to help make angioplasty even better than it is. The cases went well, broadcast to one of the main arenas in Washington DC.

Dr Malik said: “We have an expertise in assessing and treating Coronary artery disease. Sometimes the safest thing to do is keep on the tablets and not have stents or surgery. If stents are needed, then it can often useful to look inside the artery with ultrasound, rather relying on just the X-ray angiogram. I do this routinely in my practice”

Coronary Angioplasty PCI

PFO: Patent Foramen Ovale

A PFO is a small flap in the heart present in 1/4 of the whole population.

It is present in 50% of young strokes that have no obvious cause.

The RESPECT trial suggested benefit from closing the PFO with an umbrella device. After a long think, the Food And Drug Administration (FDA) has agreed that this can be a useful procedure.

The final results of the RESPECT trial at 5 years follow up should be coming soon.

Dr Malik has a large experience of PFO Closure in divers and patients with stroke.

To find out more click here


Dr Boon Lim – BBC World Today. 28/10/2016

Dr Boon Lim, Consultant Cardiologist and Electrophysiologist was interviewed on BBC radio to discuss the use of modern technology algorithms in improving diagnosis and treatment of patients with heart rhythm abnormalities. Dr Lim uses modern mobile technology such as the AliveCor mobile ECG recording device to help make rapid diagnosis and guide treatment for patients who are suffering with heart rhythm abnormalities, particularly Atrial Fibrillation (AF). Dr Lim is a specialist in treatment of AF and performs ablation procedures using state of the art mapping technologies to improve patient outcomes. He is frequently invited to speak on his experience on treating complex heart rhythm abnormalities including AF and atrial tachycardia, at national and international conferences.

Dr Boon Lim – New mapping technologies for AF ablation

Use of ultra-high density mapping to treat complex atrial tachycardia (AF) following ablation for atrial fibrillation (AF)boon

Dr Boon Lim was invited to speak at the recent Heart Rhythm Congress in Birmingham in Oct 2016 on his experience using the ultra high density mapping system (Rhythmia).

Dr Lim shared his experience with other cardiologists and physiologists using this mapping system to treat complex arrhythmias occurring after previous ablation procedures.

rhythmia-exampleThese atrial tachycardias could be mapped rapidly and treated effectively with the novel mapping system, available at Imperial College Healthcare based at Hammersmith Hospital.  Dr Lim is one of the pioneers in use of this technology for this purpose of mapping complex atrial arrhythmias and atrial fibrillation (AF) and leads several clinical trials in the use of these complex mapping technologies for treating heart rhythm disturbances.


Dr Lim is a clinical electrophysiologist dedicated to improving patient outcomes in patients who have atrial fibrillation. He is a specialist AF ablation expert and lectures at National and International Meetings on these novel mapping and ablation strategies to help produce best outcomes for patients with arrhythmia.


Dr Malik: TAVI (Transcatheter Aortic valve Intervention) Cases

Dr Malik performs complex surgery. Here are two recently published case reviews.

How about a 90 year of with previous Aortic valve surgery and a a lot of metalwork in the aorta. A new TAVI valve was placed and the patient did very well. TAVI (Transcatheter Aortic valve Intervention) is a remarkable treatment for those with aortic valve disease in whom open heart surgery is anything but low risk.


This patient was at intermediate but not high risk for open heart surgery. The new TAVI valve appeared to develop a clot on it. Dr Malik used a novel strategy of a NOAC (blood thinner) rather than Warfarin. The patient is doing very well one year later, with the valve much improved and functioning well.