Indicatie voor ablatie bij voorkamerfibrillatie. Andrea Sarkozy Cardiologie Universitair Ziekenhuis Antwerpen

Transcription

1 Indicatie voor ablatie bij voorkamerfibrillatie Andrea Sarkozy Cardiologie Universitair Ziekenhuis Antwerpen

2 Definition and Classification of AF - Practical aspects Classification of AF Paroxysmal, persistent, long-standing persistent, permanent Electrical CV 48 hours or < 7 days = paroxysmal AF Calkins H: Europace. 2012;14:528, January C: JACC 2104

3 Klinische presentatie van VKF Nattel S: Eur Heart J 2014;35:

4 Natural history of AF - progression Yearly progression from paroxysmal/persistent to permanent AF: 3.7%-15% Age, persistent AF, LA size Heart failure, Age, TIA/Stroke, COPD, HTN, (HATCH) 2 sleep apnea, obesitas De Sisti PACE 2013;37:345, 2 De Vos JACC 2010;55:725-31

5 Vroegtijdig interventie concept AF geinduceerde elektrische en strukturele remodelling Onderliggende CV ziekte veroorzaakt substraat remodelling Veroudering geassocieerde substraat Nattel S: Eur Heart J 2014;35:

6 Pulmonary vein isolation with catheter ablation

7 Interventional EP laboratory

8 Atrial Fibrillation: Catheter ablation of PV focus

9 TEE and fluoroscopy guided transseptal puncture

10 3D electroanatomical mapping Placement of a circular mapping catheter (LASSO) and irrigated tip ablation catheter in the LA

11 Circumferentiel Pulmonary vein siolation with RF ablation

12 Indications for catheter ablation in AF Good indications Alternative drug therapy: failed / contraindicated / side effects Benefit: High and long term decrease in AF recurrence - efficacy Risk: as few as possible complications

13 Efficacy

14 Meta analysis of ablation efficacy Paroxysmal AF 1 y single procedure success: 69 % 5 y single procedure success: 62%, multiple procedure: 79% Persistent AF 1 y single procedure success: 52 % 3 y single procedure success: 42%, multiple procedures:77% Ganesan JAMA 2013;2:4549

15 Efficacy of persistent, long-standing persistent atrial fibrillation ablation Star AF study Multicenter randomized trial of 589 pts in 12 countries with persistent AF Single procedure success at 18 months off AAD for PVI alone: 48% Two procedures + AAD for PVI alone: 72% Verma New Eng J Med 2015

16 Efficacy as compared to antiarrhythmic drugs Khan Circulation AEP 2014;7:853

17 Earlier ablation is associated with improved outcome 4535 paroxysmal-persistent AF pts w ablation 1m to > 5y after first diagnosis 1 year AF recurrence, death, HF hospitalization highest in most delayed group Bunch TJ et al: Heart Rhythm 2013;10:1257

18 Early ablation in patients without structural heart diseases might slow AF progression 899 pts w median follow up 64 months, AF progression: 6.4% Progression persistent:10%, long-standing persistent:14,6%, paroxysmal: 2,7% Progression w comorbidities/cardiomyopathies: 29.9% vs lone AF: 9.1% Scaglione Heart Rhythm 2104

19 Very long-term efficacy of catheter ablation 445 pts free of AF 1 y postablation followed for additional 66 months At 5 years 16,3% and 10 years 29,8% recurrence Persistent AF and hypertension are independent risk factors Steinberg JS Heart Rhythm 2104

20 Decreased Stroke rate following ablation AF ablation patients have a significantly lower risk of stroke compared to AF patients who do not undergo ablation independent of baseline stroke risk score and age However, currently following AF ablation anticoagulation is based on CHADS-VASC score irrespective of the result of the ablation Bunch J Heart Rhythm 2013;10:1272

21 Efficacy of atrial fibrillation ablation in paroxysmal AF Smart AF Trial using CF sensing catheter Prospective, multicenter, nonrandomized trial of 171 pts with PAF at 21 sites Single-procedure 12 m success off AAD therapy: 72%, with CF in operator targeted range: 81% Natale JACC 2014;64:647-56

22 Safety

23 AF ablation USA database: ablation Deshmukh Circulation 2013;128:2104

24 Safety of catheter ablation therapy as compared to drugs Calkins Circulation Arrhythmia 2009;2:349

25 Update on Indications of catheter ablation

26 2012 ESC AF Guideline update, 2012 HRS/EHRA/ECAS Expert Consensus Statement on AF Ablation, 2014 AHA/ACC/HRS AF guideline Camm AJ Eur Heart J. 2012;33:2719

27 Practical aspects Personalized informed consent over efficacy and complications of the ablation procedure

28 Conclusions Paroxysmal, Persistent, and Permanent AF classification should be used Progression rate from paroxysmal to permanent AF is yearly 5% Age, persistent AF, HTN, left atrial dilatation and structural heart and pulmonary disease are predictors Early interventions might slow progression Delay in AF ablation is associated with worse outcome

29 Conclusions Catheter ablation is recommended (class I) in symptomatic paroxysmal AF following failure of one AAD (before amiodarone) As first line therapy (class IIa) - in case AAD drugs are contraindicated Personalized informed consent: Single procedural 12 months success: 70% - 80%, 5y multiple procedures 80% - 85% Major complications: 4-5% RF ablation can be considered (class II/a) in symptomatic persistent AF following failure of one AAD Older pts with dilated LA + structural HD have high recurrence/ progression rates AAD postablation is frequently needed Personalized informed consent: Single procedural 12 months success: 50-60%, 5y Multiple procedures:70-75%