Catheter Ablation of Arrhythmias: Are the Results Different in the Elderly Patients?

Transcription

1 Catheter Ablation of Arrhythmias: Are the Results Different in the Elderly Patients? Eleftherios M. Kallergis MD, PhD, FESC Cardiology Department Heraklion University Hospital 8th IICE Thessaloniki 2015

2 Definition of Ageing Old age stages Young-Old (65-74) Middle-Old (75-84) Old-Old ( 85) Anyone who stops learning is old, whether at 20 or 80. Anyone who keeps learning stays young. The greatest thing in life is to keep you mind young! Henry Ford WHO

3 Population ageing

4 Age Pyramid for Greece due to rising life expectancy declining fertility rates The EHRA White Book 2014

5 Time modifies many biologic processes

6 Why should we care? Epidemiology of Arrhythmias in Older Adults

7 PSVT Epidemiology The prevalence was 2.25/1,000 persons and the incidence was 35/100,000 person-years AVNRT AVRT AT 0 PSVT Michael J. Porter et al. Heart Rhythm 2004

8 Incidence of PSVT by Age and Sex Dariush Mozaffarian et al. Circulation. 2015

9 Distribution PSVT Mechanism by Age The influence of age upon the PSVT mechanism is highly significant Michael J. Porter et al. Heart Rhythm 2004

10 Atrial Fibrillation Prevalence Feinberg WM, Arch Intern Med. 1995

11 Atrial Fibrillation Incidence Krahn AD, et al. Am J Med 1995, Mozaffarian et al. Circulation 2015

12 Atrial Fibrillation an Epidemic Disease The number of adults with AF is projected to continue to increase as the population ages For men and women 40 years of age and older, the remaining lifetime risk for development of AF is approximately 1 in 4

13 Incidence of Atrial Flutter in the General Population 5/100,000 person-years in those <50 years old to 587/100,000 person-year among individuals 80 years Granada J, et al. J Am Coll Cardiol. 2000

14 Arrhythmia Management in the Elderly: Challenges Fragile, multiple co-morbidities, including cardiovascular and non-cardiac disease Higher thrombo-embolic and bleeding risks Age-related degenerative changes in the cardiac conduction system More sensitive to proarrhythmic effects of drugs (decreased renal and hepatic function) Drug intolerance or polypharmacy

15 Ablation Therapy in Elderly Patients: Real World

16 Ablation Therapy in Elderly Patients European Heart Rhythm Association survey , ,8 7, ,6 10,7 pts (%) 0 AVNRT AP His AF AT/Afl VT J. Chen et al. Europace 2015

17 Age limits for different therapies in elderly patients (% of centres) European Heart Rhythm Association survey J. Chen et al. Europace 2015

18 Elderly patients not receiving the Indicated Therapies (% of centres) European Heart Rhythm Association survey J. Chen et al. Europace 2015

19 Reasons for Withholding AblationTherapy European Heart Rhythm Association survey ,7 44,9 32,7 22,5 12,2 comp ref stroke bleeding renal (%) J. Chen et al. Europace 2015

20 Safety and Efficacy of Ablation Therapy in Elderly: Real World Data European Heart Rhythm Association survey , , ,6 28,6 24,5 Safety Efficacy 10 0 No differnce Higher elderly 4,1 Lower elderly Arr type J. Chen et al. Europace 2015

21 Arrhythmias Ablation in Elderly: Do we have Scientific Evidence?

22 PSVT Ablation in Elderly Author/ Year Arrhythmia Type of study Outcome Results Complications Results Rostock et al AVNRT observational, n = 285 Yes Older not inferior Yes Older not inferior Kihelet al AVNRT observational, n = 276 Yes Older not inferior Yes Older not inferior Haghjoo et al AVNRT observational, n = 268 Yes Older not inferior Yes Older not inferior Chen et al AVNRT/ AVRT observational, n = 408 Yes Older not inferior Yes Older not inferior Dagres et al PSVT observational, n = 131 Yes Older not inferior Yes Older not inferior Pedrinazzi et al PSVT observational, n = 605 Yes Older not inferior Yes Older not inferior

23 Atrial Flutter Ablation in Elderly Clinical characteristics according to age subsets Brembilla-Perrot B, PLoS ONE 2015

24 Procedural and post-procedural events according to age subsets AFL ablation appears to be a safe and efficient and should thus be encouraged in this particular age group Brembilla-Perrot B, PLoS ONE 2015

25 Long-term AF control after AF ablation 1,165 patients, 1,506 AF ablation procedures over a 7-year period Elderly are more likely to remain on AADs and less likely to undergo repeat procedures Zado et al. Journal of Cardiovascular Electrophysiology 2008

26 Incidence and number of complications in the three age groups Major Complications Minor Complications P=NS 15 P=NS ,9 1,6 1, , ,9 3 0 < < Zado et al. Journal of Cardiovascular Electrophysiology 2008

27 Ablation versus Drugs in Elderly Persistent AF Baseline Characteristics of Study Population Blandino A et al. J Cardiovasc Electrophysiol 2013

28 Ablation versus Drugs in Elderly Persistent AF 100 SR Maintenance at Long-Term Follow-Up P = P < AF abl AADs procedure 2 procedures 18% of pts underwent redo procedures 25% continued AAD prophylaxis Blandino A et al. J Cardiovasc Electrophysiol 2013

29 Acute and Long-Term Adverse Events Blandino A et al. J Cardiovasc Electrophysiol 2013

30 Ablation versus Drugs in Elderly Persistent AF After a mean follow-up of 60 ±17 months, catheter ablation is more effective in maintaining SR than AADs success rate of 76% versus 46%, respectively (P < 0.001) 18% of pts underwent redo procedures while 25% continued AADs CA in elderly patients is affected by a higher risk of periprocedural TIA/stroke, particularly in those patients with previous history of TIA/stroke. Compared with AAD therapy, catheter ablation is associated with a significant greater improvement in QoL subscale scores Blandino A et al. J Cardiovasc Electrophysiol 2013

31 Catheter Ablation of Atrial Fibrillation in Octogenarians 103 octogenarians underwent RFCA of drug-refractory AF 3.7% of the entire patient population (4 patients with >90 years) Santangeli P et al. J Cardiovasc Electrophysiol 2012

32 Prevalence of nonpulmonary vein triggers par AF non-par AF 80 < 80 Santangeli P et al. J Cardiovasc Electrophysiol 2012

33 Catheter Ablation of Atrial Fibrillation in Octogenarians Long-Term Outcomes 100 P=0.65 P= paroxysmal AF P = Pts 80 years Pts <80 years Pts 80 years Pts <80 years procedure 2 procedures 0 1 procedure Santangeli P et al. J Cardiovasc Electrophysiol 2012

34 Catheter Ablation of Atrial Fibrillation in Octogenarians: Complications Patients 80 years (n = 103) Patients <80 years (n = 2,651) p RFCA in this age group has effectiveness similar to younger patients, without increased risk of complications Santangeli P et al. J Cardiovasc Electrophysiol 2012

35 Catheter Ablation of Arrhythmias in the Elderly

36 Conclusion Catheter ablation of SVT is an excellent therapy option for geriatric patients as effective and safe as in young adults Catheter ablation of AF can be safely performed in an elderly population There may be a slightly increased risk of peri-procedural complications Catheter ablation appears to be efficacious in an elderly population All data based on retrospective analyses More elderly remain on AADs post-ablation This may be an acceptable endpoint for an elderly patient with symptomatic AF The next step is to perform large scale, randomized trials to more definitively establish the role of catheter ablation in treating elderly patients with cardiac arrhythmias, especially atrial fibrillation