Fibrosis and Atrial Fibrillation: From a Mapping Perspective

Interview With Sanjiv Narayan, MS, MD, PhD

Dr Sanjiv Narayan discusses atrial fibrillation and cardiac fibrosis, and what he is looking forward to at the Western Atrial Fibrillation Symposium, taking place February 24-25, 2023.

Can you briefly introduce yourself and the focus of your work?

My name is Sanjiv Narayan, and I am a faculty member and electrophysiologist at Stanford University. Dr Nassir Marrouche has asked me to speak about “Fibrosis and Atrial Fibrillation (AF), the Chicken and the Egg: From a Mapping Perspective.”

What is new or novel about this topic? Summarize the background and relevance of the topic. 

Yes, so I think this is really central to the whole field. We know that AF should be treated early. Many of us in the field have been pushing that for years and years, and now randomized trials show that—the earlier you treat to maintain sinus rhythm, the better. The big question is, what do you do? We know what to do in relatively simple cases—pulmonary vein isolation or potentially using antiarrhythmic drugs. But what happens when things get more tricky, when people initially fail those strategies? And a big player that we do not fully understand is atrial scarring or fibrosis, or as I will talk about, atrial cardiomyopathy.

So what is new or novel? For decades, we have seen AF as something that you pick up on the electrocardiogram (ECG). It is an electrical disease, and at some level, it is. But now we know that there is a structural problem that goes with it. This was first picked up by John Camm's lab and others literally 20 years ago, showing that there are patches in the atria that have low voltage. Then, Nassir’s work showed that you could potentially detect that with magnetic resonance imaging (MRI), but we do not know what that is. We do not know if that is the result of AF, indicating progressive disease. We do not know if it could be, in some people, the beginning—we know that some people who do not yet have AF actually have that scar or fibrosis. So maybe that is what gets started and the AF in some patients may cascade from that. This is really key, because we know that these areas of fibrosis predict worse outcome, they predict worse response to treatment, and they even predict stroke—all the things that we care about and need to fix. So, I will be talking along with others about how to detect this and what the best approach is, whether it is MRI or other forms of imaging, potentially computed tomography in the ventricle or potentially in the atrium, using a catheter or using the ECG. And then, what to do when you have it? Can you provide better prediction or actually guide treatment? It is very controversial at the moment, so it is going to be an exciting set of sessions.

What are you most looking forward to at the Western AFib Symposium?

I think that it is really great to have a mix across the whole international spread. The speakers will be discussing gaps in current state of the art. Our peers going to be talking about gaps in pulsed field ablation. Hugh Calkins and others will be talking about how to change guidelines. Still others are going to be talking about emerging approaches to map AF and the use of artificial intelligence. And of course, there will be fellows sessions. So I think the whole meeting is fabulous and I am looking forward to all of it.