Role of Ablation of AF and PVCs in the Management of Heart Failure

Transcription

1 Role of Ablation of AF and PVCs in the Management of Heart Failure Cara Pellegrini, MD, FHRS Acting Chief, Cardiology, SF VA Associate Professor of Medicine, UCSF Disclosures I have nothing to disclose 1

2 AF Ablation Case #1 Mrs. A. was diagnosed with heart failure and atrial fibrillation 6 months ago. Since then she has not returned to her baseline of being able to walk 1 mile. She is anxious about the side effects of amiodarone, and asks you about AF ablation. You say: A. Your heart failure makes ablation too high risk B. Yes, ablation might even improve your heart failure symptoms C. Ok, but know that your likelihood of a successful ablation is much lower due to your heart failure 2

3 Case #1 Mrs. A. was diagnosed with heart failure and atrial fibrillation 6 months ago. Since then she has not returned to her baseline of being able to walk 1 mile. She is anxious about the side effects of amiodarone, and asks you about AF ablation. You say: A. Your heart failure makes ablation too high risk B. Yes, ablation might even improve your heart failure symptoms C. Ok, but know that your likelihood of a successful ablation is much lower due to your heart failure 2 Questions How successful is AF ablation in decreasing AF burden and symptoms in those with heart failure? Does AF ablation in patients with HF improve LV function, prognosis and/ or HF symptoms? 3

4 AF Prevalence in HF Maisel and Stevenson, Am J Cardiol 2003 Vicious Cycle Maisel and Stevenson, Am J Cardiol

5 Rhythm Control: Helpful? Roy et al, NEJM 2008 Right goal, wrong path AFFIRM substudy: Sinus rhythm, treatment, and survival Sinus rhythm HR 0.53 (99% CI ) Antiarrhythmic drugs HR 1.49 (99% CI ) The AFFIRM Investigators, Circulation

6 Efficacy of AF Ablation in Heart Failure Patients HF Patients Mean f/u 23 months AF-free (with AADs)* 60% AF-free 1 procedure 40% Redo procedures 32% Major complications 4.2% * 1/3 on amiodarone Anselmino et al, Circ Arrhythm Electrophysiol 2014 Comparative Efficacy HF Patients Gen Pop Mean f/u 23 months 14 months AF-free (with AADs) 60% 77% AF-free 1 procedure 40% 72% Redo procedures 32% 26% Major complications 4.2% 4% Anselmino et al, Circ Arrhythm Electrophysiol 2014 Calkins et al, Circ Arrhythm Electrophysiol

7 Caveats Efficacy overestimated in both groups Insufficient monitoring (no ILRs) 1-2 year f/u only Differences between groups F/u duration Monitoring strategy Proportion on AADs Ablation technique? Generalizable to your practice population? Age, comorbidity burden Accessibility of experienced operators Long-term AF Freedom Days to AF Recurrence Bunch et al, JCE

8 Long-term AF Freedom HF Pop General Pop Days to AF Recurrence Bunch et al, JCE 2015 Weerasooriya et al, JACC 2011 Time to Ablation Affects Outcomes Bunch et al, Heart Rhythm

9 Heart Failure Outcomes 40% 53% Anselmino et al, Circ Arrhythm Electrophysiol 2014 RCT: PABA-CHF LVEF 6 min walk HF symptoms Khan et al, NEJM

10 RCT: ARC-HF AblaDon Rate Control Months Jones et al, JACC 2013 RCT: ARC-HF Rate Control AblaDon AblaDon Rate Control LVEF BNP Rate Control HF symptoms AblaDon Jones et al, JACC

11 AblaDon RCT: CAMTAF AblaDon Rate Control VO2 Rate Control LVEF Rate Control Peak Rate Control AblaDon AblaDon NYHA class HF symptoms Hunter et al, Circ Arrhythm Electrophysiol 2014 Summary AF Ablation AF ablation efficacy and safety similar to non-hf population Note lower single-procedure success Better outcomes with ablation sooner after AF onset Please refer early HF outcomes improve with time This benefit is more than resolution of a tachycardiainduced cardiomyopathy 11

12 PVC Ablation Case #2 Mr. Z. has a h/o CAD with previous LVEF of 45%. Recently he has been short of breath with grocery shopping. On exam JVP is elevated and heart sounds are irregular. Holter: PVCs 30%. Echo: LVEF 30%. PVC ablation is: A. Less efficacious than amiodarone B. Of minimal benefit outside of PVC-induced cardiomyopathy C. Potentially useful, but high risk in low EF patients D. An appropriate first-line treatment for this patient 12

13 Case #2 Mr. Z. has a h/o CAD with previous LVEF of 45%. Recently he has been short of breath with grocery shopping. On exam JVP is elevated and heart sounds are irregular. Holter: PVCs 30%. Echo: LVEF 30%. PVC ablation is: A. Less efficacious than amiodarone B. Of minimal benefit outside of PVC-induced cardiomyopathy C. Potentially useful, but high risk in low EF patients D. An appropriate first-line treatment for this patient 3 Questions What predicts development of PVC-induced cardiomyopathy? PVC-induced cardiomyopathy vs. PVC-worsened cardiomyopathy is the distinction even important? Who should be referred for ablation and what outcomes might I expect? 13

14 Again, bidirectional Bhushan and Asirvatham, Current Heart Failure Reports 2009 PVC Burden > 24% Baman et al, Heart Rhythm

15 Predictors of PVC-Induced Cardiomyopathy PVC burden Epicardial focus Broader PVC-QRS complex (+ sinus QRS complex) Carballeira et al, Heart Rhythm 2014 Yokokawa et al, Heart Rhythm 2013 Variable Coupling Interval Large coupling interval dispersion predicted presence of LV dysfunction Kawamura et al, JCE

16 Predictors of PVC-Induced Cardiomyopathy PVC burden Epicardial focus Broader PVC-QRS complex (+ sinus QRS complex) Variable coupling interval NOT heart rate Note: PVC-induced cardiomyopathy is entirely distinct entity from tachycardia-induced cardiomyopathy Dyssynchrony Carballeira, et al, Heart Rhythm 2014 Yokokawa et al, Heart Rhythm 2013 Olgun et al, Heart Rhythm 2011 *Management Aside Asymptomatic status also reported as predictor Delayed med attention? Asymptomatic and normal LVEF -> reasonable to treat conservatively, BUT important to perform regular follow-up, ie yearly echocardiogram. 16

17 RCT: Ablation vs meds RVOT PVCs Ling et al, Circ Arrhythm Electrophysiol 2014 Ablation outcomes 84% = Short term success 85% = Long-term success with drugs 71% = Long-term success without drugs RVOT >> LVOT >> papillary muscle >> epicardium Complications 5% overall, 2.4-3% major Latchamsetty et al, JACCEP

18 LVEF change with ablation 7.7% improvement Zang et al, Heart 2014 Subgroup: LVEF < 50% 12.4% improvement Zang et al, Heart

19 Time course of LVEF recovery LVEF recovery usually 4 mo 1/3 only partial improvement early; mean recovery 12 mo (up to > 45 mo) Baman et al, Heart Rhythm 2010 PVC burden correlates with LVEF improvement Penela et al, JACC

20 Those with structural heart disease also benefit % PVC LVEF NYHA class Penla et al, JACC 2013 PVC-worsened cardiomyopathy High PVC burden (> 5%, but generally > 20%) LVEF reduction out of proportion to MRI scar Potentially reversible component of LV dysfunction! May avoid ICD implantation Ablation success rates lower in non-ischemics Intramural PVC foci Pleomorphic PVCs 20

21 Consider ablation referral High PVC burden Monomorphic / dominant morphology Symptomatic or decline in LVEF LVEF out of keeping with scar PVC Ablation Can Impact CRT Response 13% of CRT nonresponders Higher PVC burden predicted LVEF improvement Benefit largely related to increase in BiV pacing Lakkireddy et al, JACC

22 Summary PVC Ablation PVC burden is dominant predictor of development LV dysfunction; other factors contribute PVC ablation often favored over antiarrhythmics Relatively high success : complication Improves LV systolic function Greatest benefit = higher PVC burden and worse LV function at baseline Distinction between PVC-induced vs. PVCworsened cardiomyopathy not essential in patient selection for ablation Thank you! Cara.Pellegrini@ucsf.edu 22

23 Extra slides HF population Meta- Analysis Age 59 years 38% Female 5% Long-standing persistent AF (45% Paroxysmal) 3 ½ years since AF diagnosis Mean LVEF 40% 23

24 Efficacy 1 procedure Anselmino et al, Circ Arrhythm Electrophysiol 2014 Efficacy of Ablation Anselmino et al, Circ Arrhythm Electrophysiol

25 Ablation complications Anselmino et al, Circ Arrhythm Electrophysiol

26 MacDonald (small RCT AF ablation vs med therapy) Add for longer talk Predictors of AF Ablation success More on TCM subgroup More on mechanism PVCs and pulm sarcoidosis / AVCD More on PVC presentation, etc 26