Παροξυσμική Κολπική μαρμαρυγή σε νέο άτομο 40 ετών

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Clifford Hilary Mosley
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1 Παροξυσμική Κολπική μαρμαρυγή σε νέο άτομο 40 ετών Ιωάννης Σκιαδάς MD, FESC, EHRA Accredited in Cardiac Pacing Καρδιολογικό Τμήμα Ιπποκράτειο ΓΝΑ

3 Prevalence, percent AF Prevalence: Age and Gender Prevalence of atrial fibrillation with age 12 Women Men < >85 JAMA 2001; 285: 2370 Age, years

5 Incidence of stroke per 1000 person-years Incidence of stroke in AF patients increases with age Incidence of stroke after diagnosis of AF (men) Age (yrs) 22-year follow-up of men in the Danish National Registry of Patients Frost L et al. Neuroepidemiology 2007;28:109 15

6 Μάρτιος 2014

7 Types of Atrial Fibrillation European Heart Journal (2010) 31,

10 AF in Reversible clinical conditions

11 Priorities in the Management of AF The Patient Care Pathway Rhythm Control Prevention of Thromboembolism Rate Control

12 Polypharmacy and Non-adherence Strongest predictor of non-adherence is the number of medications Non-adherence rates estimated 25-50% Intentional about 75% of the time Changes in regimen made by patients to: - Increase convenience - Reduce adverse effects or - Decrease refill expense

13 Antiarrhythmic Drugs to Maintain Sinus Rhythm Recommendations COR LOE Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. I C The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities: a. Amiodarone b. Dofetilide c. Dronedarone d. Flecainide e. Propafenone I A f. Sotalol The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug. I C

14 Antiarrhythmic Drugs to Maintain Sinus Rhythm (cont d) Recommendations COR LOE Because of its potential toxicities, amiodarone should only be used after consideration of risks and when other agents I C have failed or are contraindicated. A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of IIa C tachycardia-induced cardiomyopathy. It may be reasonable to continue current antiarrhythmic drug therapy in the setting of infrequent, well-tolerated recurrences of AF when the drug has reduced the frequency or symptoms of AF. IIb C Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent, including dronedarone. III: Harm C B

15 AF Catheter Ablation to Maintain Sinus Rhythm Recommendations COR LOE AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is I A desired. Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual I C patient is recommended. AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least IIa A 1 class I or III antiarrhythmic medication. In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy. IIa B

18 Stroke is a frequent complication of AF Stroke is the leading complication of AF AF is associated with a 5-fold higher stroke risk overall 1 Without preventive treatment, each year approximately 1 in 20 patients with AF will have a stroke 3 When TIAs and clinically silent strokes are considered, the rate of brain ischemia associated with nonvalvular AF exceeds 7% per year AF is responsible for 15% of all strokes, and AF is the leading cause of embolic stroke 4 1. Savelieva I et al. Ann Med 2007;39:371 91; 2. Fuster V et al. European Heart Journal 2006;27: ; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154: ; 4. Benjamin EJ et al. Circulation 1998;98:

19 Κολπική μαρμαρυγή και βαρύτητα εγκεφαλικού επεισοδίου Wolf PA, et al. Stroke 1991; 22:

$AF in drug refractory cases (Class$

25 Ablation : Υπόθεση ρουτίνας? ACC/AHA/HRS GL 2014 for paroxysmal AF in drug refractory cases (Class I) and as first-line therapy (Class IIa)

27 Primum Non Nocere First, do no Harm. Hippocrates, 4th Century BC

28 PV Foci Triggering Afib 94% of foci located inside PV (2-4 cm from ostium) 45% in LSPV, 25% in RSPV, 16% in LIPV, 9% in RIPV Right Atrium Left Atrium Superior vena cava 25 % 45 % Pulmonary Veins Inferior vena cava Fossa ovalis Coronary sinus 9% 94% 16 % Haïssaguerre M, et al. N Engl J Med (1998) 339: 659

29 Ostial PV Isolation Atrial activation preceding PVP Discharges from PV Local PV activity dissociated distally at a slow rate Haïssaguerre M, et al. Circulation (2000) 101: 1409

30 Catheter Ablation Techniques From the first procedures to today

31 Maze reproduction Schwarz 1994 Right atrial linear lesions Haïssaguerre 1994 Right and left atrial linear lesions Haïssaguerre 1996 PV foci ablation Landmarks in Catheter Ablation Technique Techniques Jaïs / Haïssaguerre 1997/8 Ostial PV isolation Haïssaguerre 2000 Circumferential PV ablation Pappone 2000 Ablation of non-pv foci Lin 2003 Antral PV ablation Maroucche / Natale 2004 Double Lasso technique Ouyang / Kuck 2004 CFAE sites ablation Nademanee 2004 Ostial or circumferential or antral PV ablation plus extra lines (mitral isthmus, posterior wall, roof) Circumferential PV ablation with vagal denervation Publication date Jaïs / Hocini 2004/5 Pappone 2004

32 CRYOABLATION Key principles

33 Ice Formation Video

34 Arctic Front Advance Cryoballoon Catheter

35 Artic Front Advance

36 Cryo Properties Cryoadhesion ensures stability Cryoanalgesia reduces perceived pain Cryo preserves endothelial integrity and hence reduces incidence of thrombus formation

37 MORE DISTAL COOLING MORE UNIFORM COOLING INJECTION PORTS Arctic Front Arctic Front Arctic Front Advance 4 8 Arctic Front Advance AF Advance 28mm flow increased to 7200sccm 37

38 Variable PV Diameter Arctic Front (1 st Gen) Arctic Front Advance (2 rd Gen) 38

39 Learning Curve to Success Rate

40 STOP AF Primary Effectiveness Arctic Front Cryoballoon Packer DL, Kowal RC, Wheelan KR, et al. Cryoballoon Ablation of Pulmonary Veins for Paroxysmal Atrial Fibrillation: First Results of the North American Arctic Front (STOP AF) Pivotal Trial. J Am Coll Cardiol. April 23, 2013;61(16):

Single Procedure Freedom from AF, AT and AFL Arctic Front Advance Cryoballoon Single Center Published Studies Single Procedure Freedom From AF, most off AAD Arctic Front Cryoballoon Arctic Front

001 64% 80% 83% 85% 85% 80% 82% 60% 40% 20% 0% Di Giovanni (n=100) Fürnkranz (n=105) Aryana (n=340) Aytemir (n=306) Greiss (n=376) Metzner (n=49) Chierchia (n=42) Kumar (n=40) Jourda (n=75) Ciconte

41 Single Procedure Freedom from AF, AT and AFL Arctic Front Advance Cryoballoon Single Center Published Studies Single Procedure Freedom From AF, most off AAD Arctic Front Cryoballoon Arctic Front Advance Cryoballoon 100% 91% 90% 80% 84% 84% p=0.038 p= % 64% p=ns 81% 82% p= % P< % 80% 83% 85% 85% 80% 82% 60% 40% 20% 0% Di Giovanni (n=100) Fürnkranz (n=105) Aryana (n=340) Aytemir (n=306) Greiss (n=376) Metzner (n=49) Chierchia (n=42) Kumar (n=40) Jourda (n=75) Ciconte (n=143) Di Giovanni, et al. J Cardiovasc Electrophysiol. 2014; 25(8):834-9, Fürnkranz, et al. Journal of Cardiovascular Electrophysiology 2014 ;25(8):840-4, Aryana, et al. J Interv Card Electrophysiol 2014;41(2): , Aytemir, et al. Europace; 2015;17(3):379-87, Metzner, et al. Circ Arrhythm Electrophysiol. 2014; 7(2): , Chierchia, et al. Europace 2014; 16(5): , Kumar et al. J Interv Card Electrophysiol 2014;41(1):91-7, Jourda, et al. Europace 2015;17(2):225-31, Ciconte, et al. Heart Rhythm 2015;12(4):673-80, Wissner, et al. Europace 2015, In Press. Wissner (n=45) 41

42 Cryo vs. RF Trial HRS 2014 Late Breaking Trial 5/9/14 St. Bartholomew Hospital (London UK) 237 patients with paroxysmal AF were randomized 1:1:1 to RF WACA ablation 1, Cryo 2 or a combined approach 3 Procedure time was 211 (IQR ) mins for RF compared to 167 ( ) mins for Cryo (p<0.001) 1. RF WACA: Wide encirclement of the PVs using an irrigated radiofrequency ablation catheter guided by a 3D mapping system. 2. Cryo: Pulmonary vein isolation using the Arctic Front Cryoballoon. 3. Combined: RF WACA wide encirclement of the PVs to achieve PV isolation, followed by 2 empirical applications of the cryoballoon to each PV ostia. Cryo vs. RF RF vs. Combined Cryo vs. Combined P<0.015 p<0.001 P=0.166 Hunter, et al. HRS 2014, San Francisco. Lecture ID

PV Lesion Durability with RF and Cryo Studies evaluating PV re-conduction using repeat electrophysiology and mapping after the index procedure RF RF: Contact Sensing Arctic Front 1 2 3 4 5 (n=117)

procedure. All patients were evaluated regardless of clinical symptoms 1 Late Breaking Clinical Trials session I at the EHRA EUROPACE 2013 meeting in Athens, Greece 2 Williems, et al.

43 PV Lesion Durability with RF and Cryo Studies evaluating PV re-conduction using repeat electrophysiology and mapping after the index procedure RF RF: Contact Sensing Arctic Front (n=117) (n=40) (n=75) (n=75) (n=12) Follow-up** 3 Months 3 Months 12 months 3 months 3 months *All 4 veins were isolated in invasive remapping procedure **Time between index procedure and re-mapping procedure. All patients were evaluated regardless of clinical symptoms 1 Late Breaking Clinical Trials session I at the EHRA EUROPACE 2013 meeting in Athens, Greece 2 Williems, et al. J Cardiovasc Electrophysiol 2010; 21(10): Jiang, et al. Heart Rhythm. 2014;11(6): Neuzil et al. Circ Arrhythm Electrophysiol.(2): Ahmed, et al. J Cardiovasc Electrophysiol, 2010;21(7):731-7

Meta-Analysis of Phrenic Nerve Palsy from a Systematic Review of Published Studies with Arctic Front 539 Arctic Front articles screened, 23 were retained for the final analysis (1309 patients): 1 2

44 Meta-Analysis of Phrenic Nerve Palsy from a Systematic Review of Published Studies with Arctic Front 539 Arctic Front articles screened, 23 were retained for the final analysis (1309 patients): 1 2 PNP overall incidence of 6.38% 4.73% of PNP persisted after the ablation procedure 0.37% of patients experiencing PNP that persisted beyond 1 year. 1 Andrade, et al. Heart Rhythm 2011;8(9): , 2 Cappato et al. Circ Arrhythm Electrophysiol 2010;3:32 38

10 years of clinical experience Worldwide Cumulative Growth of Arctic Front 140.000 120.000 100.000 80.000 60.000 40.000 20.

45 Cryoballoon Has Experienced Rapid Growth in Worldwide Adoption and Clinical Experience 250+ peer-reviewed articles and numerous abstracts The Cryoballoon system is used in over 1000 centers in more than 50 countries worldwide. 10 years of clinical experience Worldwide Cumulative Growth of Arctic Front : AF FDA Approval 2012: AFA Launch Over 120,000 patients treated in over 1000 centers over the last 10 years

46 PAF στα 40 Εξατομίκευση προσέγγισης προδιαθεσικών παραγόντων ή υποκείμενων παθήσεων Λεπτό ζύγισμα ωφελειών και παρενεργειών των συντηρητικών ή επεμβατικών θεραπειών 46

47 47 Ευχαριστώ για την προσοχή σας

Κατάλυση παροξυσμικής κολπικής μαρμαρυγής Ποια τεχνολογία και σε ποιους ασθενείς; Χάρης Κοσσυβάκης Καρδιολογικό Τμήμα Γ.Ν.Α. «Γ.

Κατάλυση παροξυσμικής κολπικής μαρμαρυγής Ποια τεχνολογία και σε ποιους ασθενείς; Χάρης Κοσσυβάκης Καρδιολογικό Τμήμα Γ.Ν.Α. «Γ. ΓΕΝΝΗΜΑΤΑΣ» Rhythm control antiarrhythmic drugs vs catheter ablation Summary