Gianfranco Buja Senior Teacher University of Padova (Italy)

Transcription

1 Cardiac origin of embolic stroke New oral anticoagulation therapy for stroke prevention in patients with atrial fibrillation undergoing ablation Venice may, 5-7/ 2016 Cortile Antico Teatro Anatomico Universitas Artistarum Gianfranco Buja Senior Teacher University of Padova (Italy)

2 AF-CATHETER ABLATION HISTORY FRENCH REVOLUTION 1998 Michel Haissaguerre The Pioneer NEJM 1998

3 New oral anticoagulation therapy for stroke prevention in patients with atrial fibrillation undergoing ablation Background Non-valvular AF confers a 5-fold increased risk of stroke. The risk varies according to the presence of several risk factors (CHA2DS2-VASc) Ablation increases TE risk due to introduction and manipulation of catheters and long sheats into the LA (A), and due to endocardial lesions produced during ablation (B). The risk is dependent on Paroxysmal vs non-paroxysmal AF or PV isolation vs several linear lesions. Cryo RF A B

4 BEFORE ABLATION (W or NOACs)

5 DURING ABLATION * (*Pts. on VKA require lower heparin doses than those on a NOAC. Armbruster HL Ann. Pharmacother 2015) («Microbubbles or microparticels» M.Takami et al Circ Arrhyt Electrophysiol 2016)

6 PERIPROCEDURAL STRATEGY THE RATIONALE: 1) Performing AF ablation under therapeutic W increases the risk of bleeding. 2) Bridging with H is safer than keeping patients on W. 3) Bleeding complications are worse if patient is maintained on therapeutic W. R.Cappato Circ Arrhyt 2010 J. Chen Europace 2015

7 NOACs

8 Safety and efficacy of novel oral anticoagulants in the setting of atrial fibrillation ablation: Is it time to celebrate the «funeral» of warfarin? L. Di Biase J Int Cardiac Electrophysiol 2014;41:103

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10 QUESTION: Bridge vs Uninterrupted W??? vs

11 RANDOMIZED TRIAL

12 BLEEDING?

13 (off-w) (on-w) Long-standing AF: 33 group 1 2 group 2 Conclusions: this is the first randomized study showing that performing CA of AF without W discontinuation reduced the occurrence of periprocedural stroke and minor bleeding compared with bridging with LMWH.

14 SILENT THROMBOEMBOLIC LESIONS On-W Off-W L.Di Biase Hearth Rhythm 2014

15 JACC 2015;66:1393 Expert opinion SCORE -CHA2DS2-VASc -CHADS2 -HAS-BLED -ATRIA -ORBIT -HEMORR2-HAGES SAMe-TT2R2

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17 DABIGATRAN AND AF-ABLATION Multicenter Registry «were included mainly paroxysmal AF. When non-paroxysmal AF pts. have been included, uninterrupted dabigatran use seemed to be inferior when compared to uninterrupted W.»

18 RIVAROXABAN AND AF-ABLATION Multicenter Registry

19 APIXABAN AND AF-ABLATION Multicenter Prospective Registry L.DiBiase et al Heart Rhythm 2015

20 RIVAROXABAN AND AF-ABLATION Randomized-Controlled-Trial

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22 NOAC AND AF-ABLATION «Of note, the protective value of novel oral anticoagulants should be mainly tested in patients with non-paroxysmal AF because thromboembolic events have a low rate in paroxysmal patients»

23 Real World-VENETO REGION ACO Protocol in pts. submitted to ablation for AF 1)Padova (Courtesy Dr. F. Migliore) 2)Camposampiero (Courtesy Dr. R. Verlato) 3)Feltre (Courtesy Dr. A. Bonso) 3)Mestre (Courtesy Dr. S. Themistoclakis) 4)Treviso (Courtesy Dr. M. Crosato) Strategy in the majority of pts: -interrupted W and bridging with LMWH is preferred -NOACs interrupted 24 h pre-procedure -uninterrupted W (??) Department of Cardiac Surgery

24 OAC AFTER AF ABLATION

25 OAC TWO MONTHS AFTER AF ABLATION Seite 25

26 CONCLUSIONS «it is a bit premature to celebrate its demise («funeral») in the setting of catheter ablation for atrial fibrillation.» Safety and efficacy of novel oral anticoagulants in the setting of atrial fibrillation ablation: Is it time to celebrate the «funeral» of warfarin? L. Di Biase J Int Cardiac Electrophysiol 2014;41:103

27 Conclusions -Three weeks of OAC (VKA or NOACs) with TEE -Uninterrupted is better than interrupted VKA, INR=2-3 is desirable -Data on NOACs are so far not conclusive, stop NOACs for 24 h is recommended (we are waiting for RCTs comparing uninterrupted W vs NOACs in non-paroxysmal AF) -After AF ablation OAC (VKA or NOACs) should be continued during at least 3 months -OAC during the follow-up is not dependent on procedure success

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29 «Talent means, while the experience, gained in humility and hard work, means everything» Oscar Wilde Thanks for your attention

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31 THE PAST-THE PRESENT-THE FUTURE

32 «we are much less prone to cause medical events (bleeding) rather than aiming to prevent events (stroke).» (Anonymous)

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34 EHRA SURVEY

35 Zusammenfassung: Vor einer VHF Ablation...

36 Afib ABLATION: warfarin vs NOACs Bleeding TE SYMPTOMATIC vs SILENT -Bridge or not bridge? -Uninterrupted or interrupted? -High, moderate, low risk -Pre-Peri-Post-Procedural -Afib Parox, Pers, Perm -PV, PV+linear lesion -RF vs Cryo -Ablation catheters; ICE -Trial design (RCTs) -Guidelines or «expert opinion»

37 The Framingham Heart Study- Circulation 1998 Benjamin STROKE: Men 14% vs 9%; Women 19.9% vs 8,2% JACC 2013

38 Pharmacological or electric conversion to sinus rhythm -SYMPTOMATIC STROKE AFTER AFIB ABLATION: 0,4-0,9% -SILENT CEREBRAL EMBOLISM AFTER AFIB ABLATION: 14%

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40 Amsterdam-ESC Arrhythmias Section. Atrial Fibrillation «I have 5 milion of euro just for one young fellow (male or female 30 yo)» What is in your opinion the best way to use these funds? 1)To prevent risk factors for atrial fibrillation 2)To improve catheter ablation procedure (catheters, energy, mapping, strategy ) 3)To study new anticoagulant therapy The majority of the audience answered : 2 The winner was

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44 «have the finger in the pie» viewer

45 ATRIAL FIBRILLATION Valvular rheumatic disease Hyperthyroidism DM HBP HF Cardiomyopathy Air Pollution Sleep apnea Age Smoke Strong Physical Activity ANS Channelopathy Alcool/drugs CAD Obesity Telomere lenght

46 INTERRUPTED WARFARIN AND BRIDGING Pre-procedure: -stop warfarin 4 days before, enoxaparin, TEE Peri-procedure:-UH with ACT, echo Post-procedure:-warfarin+enoxaparin ½ after procedure (evening) during 48 h; stop enoxaparin at INR 2-3 INTERRUPTED NOACs AND BRIDGING Pre-procedure:-stop NOACs h before, enoxaparin ½ Peri-procedure:-UH ACT, echo Post-procedure: enoxaparin ½ (evening and morning after), NOACs the day after Courtesy M. Crosato, V.Calzolari, L. DeMattia

47 i NAO stop una dose singola pre procedura e ripresa la sera stessa dell'intervento. Per warfarin, embricatura con clexane, intervento con INR < 1.7; ripresa il pomeriggio stesso di warfarin, clexane fino a INR terapeutico. Ciao e grazie

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53 New oral anticoagulation therapy for stroke prevention in patients with atrial fibrillation undergoing ablation Background 1 Pts with AF have an increased risk of TE events (A), which varies according to the presence of several risk factors (B) A AF AF stroke 14% vs 9%; stroke 19.9% vs 8,2% Benjamin et al (Framingham study) Circ 1998 Iwasaki Y Circ 2011 Camm et al EHJ 2010 B

54 Bleeding risk score HAS-BLED ATRIA ORBIT

55 The match ended in a draw

56 9 studies; pts. OBSERVATIONAL STUDIES

57 AF-Catheter ablation: Risk of TE in Paroxysmal vs non-paroxysmal AF «Because the risk of TE is confined predominantly to patients with non-paroxysmal AF.future studies should enroll mainly patients with non-paroxysmal AF.» Uninterrupted warfarin vs NOACs

58 M. Haissaguerre, G. Buja 1999 AF-CATHETER ABLATION

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