Atrial Fibrillation Ablation

Transcription

1 Atrial Fibrillation Ablation THE STATE OF THE ART BASED ON THE VENICECHART INTERNATIONAL CONSENSUS DOCUMENT Edited by Andrea Natale, M.D. Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, USA Antonio Raviele, M.D. Department of Cardiology, Arrhythmia Center and Center for Atrial Fibrillation, Umberto I Hospital, Venice-Mestre, Italy

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3 Atrial Fibrillation Ablation THE STATE OF THE ART BASED ON THE VENICECHART INTERNATIONAL CONSENSUS DOCUMENT Edited by Andrea Natale, M.D. Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, USA Antonio Raviele, M.D. Department of Cardiology, Arrhythmia Center and Center for Atrial Fibrillation, Umberto I Hospital, Venice-Mestre, Italy

4 C 2007 Blackwell Publishing Blackwell Futura is an imprint of Blackwell Publishing Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts , USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia All rights reserved. No part of this publication may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review. First published ISBN: Atrial fibrillation ablation : the state of the art based on the VeniceChart international consensus document / edited by Andrea Natale, Antonio Raviele. p. ; cm. Includes bibliographical references and index. ISBN (alk. paper) 1. Atrial fibrillation Treatment. 2. Catheter ablation. I. Natale, Andrea. II. Raviele, Antonio. [DNLM: 1. Atrial Fibrillation therapy. 2. Catheter Ablation methods. 3. Treatment Outcome. WG 330 A ] RC685.A72A dc A catalogue record for this title is available from the British Library Commissioning Editor: Gina Almond Development Editor: Fiona Pattison Production Controller: Debbie Wyer Set in 9.5/12 Palatino by Aptara Inc., New Delhi, India Printed and bound in Spain by GraphyCems, Navarra For further information on Blackwell Publishing, visit our website: The publisher s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book.

5 Contents Preface, v Contributors, vii VeniceChart Task Force Composition, xxi 1 Anatomy of the left atrium and pulmonary veins, 1 2 Pathophysiology of atrial fibrilation, 11 3 Techniques and technologies for atrial fibrilation catheter ablation, 17 4 Endpoints of catheter ablation for atrial fibrilation, 29 5 Patient management pre- and postablation, 34 6 Anticoagulation issues, 41 7 Periprocedural and late complications, 51 8 Short- and long-term efficacy, 73 Index, 79 iii

6 This initiative has been made possible thanks to an unrestricted educational grant from

7 Preface Atrial fibrillation is the most common cardiac arrhythmia, with a prevalence in the general population of approximately 1% and an incidence of 0.2% per year. Both the prevalence and incidence of atrial fibrillation increase with age, reaching more than 8 and 1%, respectively, in individuals older than 80 years. Based on the above estimates, we can calculate that currently there are nearly 3 million people with atrial fibrillation in the USA and about 4.5 million in the European Union, with 600, ,000 new cases each year. This burden will likely increase in the coming decades, as consequence of the increasing age of the population and the growing proportion of elderly individuals, and it has been projected that the number of adults suffering from atrial fibrillation by the year 2050 in the USA will be from 5.6 to 15.9 million people, two to five times more than the current figure. The presence of atrial fibrillation is often associated with symptoms responsible for a significant deterioration of quality of life, and carries an increased risk of systemic thromboembolism, heart failure, and cardiovascular mortality. Thus, despite the poor efficacy of antiarrhythmic drugs, a treatment aimed at restoring and maintaining sinus rhythm, in patients with atrial fibrillation, is usually justified. In the last years, catheter ablation of atrial fibrillation has gained growing popularity as an effective and definitive cure of this arrhythmia. Introduced into clinical practice at the end of the 1990s, as a result of pioneering research conducted by Haïssaguerre and colleagues, catheter ablation of atrial fibrillation has now become a widespread treatment modality in electrophysiology laboratories all over the world. To date, various ablative techniques have been proposed and are still under assessment. However, despite the widespread diffusion, many aspects of the catheter ablation of atrial fibrillation are still controversial, from ablation techniques to procedural endpoints; patient management pre-, during, and postablation; hospital facilities, training requirements/competences; prevention and treatment of complications; and definition of success and long-term results. Consensus for these issues among the many physicians involved in the management of atrial fibrillation would be useful. Having this in mind, the Organizers of VeniceArrhythmias 2007 have assembled world-recognized experts in the field to develop an international consensus document on atrial fibrillation ablation, called VeniceChart, published in the May 2007 issue of the Journal of Cardiovascular Electrophysiology. In the present book, a more extended version of the document, enriched by several figures and tables, is presented. The text may be considered a comprehensive and up-to-date overview of all the most important and debated aspects of atrial fibrillation ablation. The final result looks excellent, and we v

8 vi Preface are confident that the book will provide a highly valuable source of information not only for the researchers and the specialists in the electrophysiology, but also for general cardiologists, internists, fellows in cardiology, and medical students. Many renowned experts have contributed to the preparation of the VeniceChart international consensus document and to the realization of this volume. Their names are reported in the list of contributors. We are deeply indebted to all of them. Without their enthusiasm and personal effort, this book would not have been possible. We are especially grateful to Eric Prystowky, Editor-in-Chief of the Journal of Cardiovascular Electrophysiology, who, since the beginning, believed in this initiative, providing all his support and experience. We have to recognize the high professionalism of Fiona Pattison, Senior Development Editor of Blackwell Publishing, who took care of the editorial aspects of the book. Furthermore, we have to thank Paolo Zavalloni, Eldaa Corposanto, and all the staff of AdriaCongrex for their invaluable assistance. We also acknowledge the important contributions of our colleagues both at the Cleveland Clinic, Cleveland, USA, and at Umberto I Hospital, Venice, Italy, in the preparation and realization of both the VeniceChart international consensus document and the VeniceArrhythmias meeting. In particular we thank Mauricio Arruda, Aldo Bonso, David Burckardt, Andrea Corrado, Jennifer Cummings, Gianni Gasparini, Franco Giada, Michela Madalosso, David Martin, Antonio Rossillo, Robert Schweichert, Walid Saliba, Patrick Tchou, Sakis Themistoclakis, and Bruce Wilkoff. Finally, our deepest appreciation and gratitude goes to our wives, Carmen and Marina, and to our children, Francesca, Eleonora, Michele, and Veronica, for their patience, personal sacrifice, and continuous encouragement. Andrea Natale and Antonio Raviele

9 Contributors Maurits Allessie, M.D., Department of Physiology, University of Maastricht, Maastricht, The Netherlands Matthias Antz, M.D., Asklepios Klinik St. Georg, Hamburg, Germany Thomas Arentz, M.D., Department of Electrophysiology, Herz-Zentrum, Bad Krozingen, Germany Mauricio Arruda, M.D., Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, USA vii

10 viii Contributors Aldo Bonso, M.D., Department of Cardiology, Arrhythmia Center and Center for Atrial Fibrillation, Umberto I Hospital, Venice-Mestre, Italy Johannes Brachmann, M.D., Department of Medicine and Cardiology, Klinikum Coburg GmbH, II. Med. Klinik, Coburg, Germany Josep Brugada, M.D., Cardiology Department, Hospital Clinic de Barcelona, Barcelona, Spain José Angel Cabrera, M.D., Department of Cardiology, Hospital Quiron, Madrid, Spain Hugh Calkins, M.D., Department of Cardiology, The Johns Hopkins Hospital, Baltimore, USA