Atrial Fibrillation New Approaches, Techniques, and Technology

Transcription

1 New Cardiovascular Horizons 2015 May 28, 2015 New Orleans, Louisiana Atrial Fibrillation New Approaches, Techniques, and Technology State of the Art Richard Abben, M D Director, Cardiac Arrhythmia Service Cardiovascular Institute of the South Associate Clinical Professor of Medicine LSU School of Medicine

2 Mechanisms Cardiac monitoring Atrial Fibrillation 2015 Advances Medical Therapy Role of Ablation Lifestyle Management Strategies

3 2.7 million US patients 5-7x increased CVA rate Anticoagulation Rx essential in most patients Drug therapy with modest benefit Ablation techniques with improved results Lifestyle changes essential

4 Atrial Fibrillation Mechanism Rapidly discharging foci that originate in pulmonary veins and disrupt normal atrial rhythm Isolation of pulmonary veins is the goal of AF ablation

5 RR = Relative Risk Event Risk Increased with AF 7 6 RR Studies 1 Framingham 2 Regional Heart Study 3 Whitehall 4 Manitoba 0 CVA Death Anticoagulation Studies Kannel et al. Am Heart J 1983;106: Curtis, A. Amer Coll Cardiol Scientific Session Flegel et al. Lancet 1987;1: Krahn et al. AM J Med 1995;98:

6 Stroke Prevention in AF Anticoagulation Trials Relative Risk Reduction (95% CL) AFSAK 1 SPAF BAATF CAFA SPINAF EAFT ALL TRIALS 100% 50% 0-50% Warfarin better Warfarin worse Dose-Adjusted Warfarin with 61% Risk Reduction of Stroke Hart et al. Ann Int Med 1999;131:

7 Atrial Fibrillation Role of Aspirin Questioned Role of aspirin in all patients for primary prevention has been questioned -JPPP (Japanese Primary Prevention Project) evaluated 14,658 patients with CV risk factors -6.5 years - - No CV death/mi reduction with aspirin -Multiple studies in progress - - ARRIVE, ASCEND, ASPREE Aspirin may not be needed in stable CAD pts on warfarin -French study examined 4184 stable CAD patients (no recent stents or MIs) -Aspirin with warfarin highest bleeding, mortality risk -Aspirin with warfarin without CV benefit Shimada, et al. AHA Scientific Sessions November, Hamon, et al. J Amer Coll Cardiol 2014;64:

8 2015 Advances Cardiac Monitoring Cardiac Electrophysiology Syncope Atrial Fibrillation Cryptogenic CVA/AF Clinical benefits of remote monitoring for arrhythmia detection and survival

9 EMBRACE trial CRYSTAL AF trial 572 patients with cryptogenic CVA or TIA Randomized to standard 24- hour Holter or 30-day ambulatory telemetry 440 patients with cryptogenic CVA Randomized to standard 24- hour Holter or implantable monitor recordings Atrial fibrillation detection Holter - 3.2% 30-day %

10 EMBRACE trial CRYSTAL AF trial 572 patients with cryptogenic CVA or TIA Randomized to standard 24- hour Holter or 30-day ambulatory telemetry Atrial fibrillation detection Holter - 3.2% 30-day % 440 patients with cryptogenic CVA Implantable monitor Randomized to standard 24-30% hour AF Holter detection or implantable at 36 monitor recordings months Atrial fibrillation detection Holter - 1.8% Implantable - 8.9%

11 Remote monitoring Current devices (Pacemakers and ICDs) record arrhythmic events and this data can be accessed remotely via wireless technology Benefits Arrhythmia detection and documentation Survival benefit!

12 Remote monitoring Current devices (Pacemakers and ICDs) record arrhythmic events and this data can be accessed remotely via wireless technology

13 ASSERT trial 2580 cardiac device patients No AF history 3-month monitoring to assess presence of AF/SVT - >190 bpm x >6minutes 30-month followup Results Clinical AF rate 15.7% vs 3.1% CVA rate 4.2% vs 1.7% p<0.01

14 ASSERT trial 2580 cardiac device patients No AF history 3-month monitoring to assess presence of AF/SVT - >190 bpm x >6minutes 30-month followup Results Clinical AF rate 15.7% vs 3.1% CVA rate 4.2% vs 1.7% p<0.01

15 Wireless monitoring study 262,000 cardiac device patients with wireless capability Patient outcomes evaluated in relation to usage of remote system High use >75% Low use <75% No use Results - - Survival High use versus Low use 53% improvement High use versus No use 140% improvement p<0.001 Mittal, S. Heart Rhythm Society Meeting, May, 2014.

16 Persistent AF (or flutter) Medical Management Strategies No conversion Rate control and anticoagulation Attempt conversion NSR maintenance and anticoagulation AF trials - - AFFIRM, RACE, STAF

17 Persistent AF (or flutter) Medical Management Strategies No conversion Rate control and anticoagulation Attempt conversion NSR maintenance and anticoagulation

18 AFFIRM Trial Rate vs Rhythm Control 4060 patients (69.2 years) Study protocol Rate control Beta, calcium blockers, digoxin AV nodal ablation Rhythm control Anti-arrhythmic agents, cardioversion 3.5 years f/u

19 Rhythm Control - - No Mortality Benefit Hospitalization rate higher with Rhythm control Trend towards higher CVA rate with Rhythm control (anticoagulation rate lower!)

20 Treatment Strategies Based on Medical Trials Rate control Reasonable approach in some patients with persistent AF Mortality similar to rhythm control group in older pts Rate control also reasonable when odds of NSR maintenance low (Marked atrial enlargement) Rhythm control The previous trials occurred before AF ablation become a standard approach Highly symptomatic Anticoagulation should be continued in most patients regardless of treatment Structurally strategy normal usedheart Younger (<70 yrs) pts Alternatives to warfarin (Thrombin and Xa inhibitors) readily available with excellent outcomes Heart failure, LV dysfunction provoked by AF when rate control is adequate

21 Rhythm Control with Medical Therapy Resistant Paroxysmal or Persistent AF Non-Ischemic No Heart Failure Flecainide, Propafenone Sotolol, Dronedarone Dofetilide Amiodarone (?Class IA) Ischemic No Heart Failure Flecainide Propafenone Sotolol, Dronedarone Dofetilide Amiodarone (?Class IA) Heart Failure, CMP (Severe LVH, EF <.35) Flecainide, Propafenone Sotolol, Dronedarone Dofetilide Amiodarone (?Class IA) Fuster et al. J Am Coll Card 2001;38(4);1266i-ixx.

22 % Sinus Rhythm Efficacy (%) of Antiarrhythmic Agents months Flecainide Benefits of Amiodarone Amiodarone Sotolol most must be balanced with effect (Multiple Dofetilidestudies) Potential side effects are reasonable options No drug Quin Diso Prop Flec Sot Dof Amio Naccarelli, G, 2004.

23 DIONISYS AF trial - - Amiodarone vs Dronedarone 504 AF pts ****Antiarrhythmic therapy relatively ineffective and has never been All side effects, including neurologic, Amiodarone % recurrence thyroid, and gastrointestinal, reduced Dronedarone % recurrence shown with to Dronedarone improve survival in AF patients! Le Heuzey, et al. J Cardiovasc Electrophysiol 2010;21:

24 Catheter Ablation of Atrial Fibrillation Potentially a Curative Approach to AF Isolation of Pulmonary Vein Triggers Pulmonary Left Vein Atrium Orifice Isolation Lines (Transseptal of ablation approach)

25 Technical Approaches in AF ablation Radiofrequency ablation Cryo, Ultrasonic Balloon ablation Convergent RF endocardial and epicardial Epicardial and endocardial lines of block created

26 After Ablation - - PV AF isolated

27 Catheter Ablation of Atrial Fibrillation Success versus Medical Therapy Quality of Life Scores Quality of Life Scores Normal Ablation Medical Normal Ablation Medical Catheter Ablation of Atrial Fibrillation Quality of Life Indicators Pappone C, et al. J Am Coll Cardiol 2003;42: Pappone C, et al. J Am Coll. Cardiol. 2006;48(11):

28 Catheter Ablation of Atrial Fibrillation Success Rates months/multiprocedure 79.8% 64.2% success at 1 year months/1 Ganesan A N, et al. J Am Heart Assoc 2013;2:e

29 AF ablation Overview Generally indicated in drug-resistant, symptomatic patients Best results in younger patients with paroxysmal AF and no structural heart disease Results have progressively Improved Recent trial demonstrated benefit in heart failure pts versus amiodarone Success rates Paroxysmal 60-80% Persistent 50-70% 2nd procedure needed in 10 20% of cases Complication rates Major < 5% Death 0.7%

30 AF ablation Overview Optimal approach to AF ablation Generally indicated in Success rates drug-resistant, symptomatic Paroxysmal 60-80% (RF, patients Ultrasound, Epicardial, Convergent, Persistent Surgical) 50-70% Best results in younger patients with paroxysmal AF and no structural heart disease has not been confirmed. 2nd procedure needed in 10 20% of cases Complication rates Major < 5% Death 0.7% AF Results is a have chronic progressively disease in many patients and risk factors, improved lifestyle of key importance!

31 AF ablation Overview Generally indicated in drug-resistant, symptomatic patients Best results in younger patients with paroxysmal AF and no structural heart disease Success rates Paroxysmal 60-80% Persistent 50-70% Cardiometabolic AF Risk Factors Obesity/OSA Diabetes Hypertension Alcohol 2nd procedure needed in 10 20% of cases Complication rates Major < 5% Death 0.7% AF Results is a have chronic progressively disease in many patients and risk factors, improved lifestyle of key importance!

32 Sleep Apnea AF ablation More AF before Overview and after Ablation patients with Sleep Apnea Generally indicated in drug-resistant, symptomatic patients ARREST AF trial Success rates Paroxysmal 60-80% Persistent 50-70% Aggressive Risk factor REducution Study for Best results in younger 2nd procedure needed patients Atrial with Fibrillation paroxysmal and Implications in 10 20% for of cases the AF and no structural Outcomes heart of Ablation disease Complication rates Major < 5% Results have progressively 281 AF ablation patients Death 0.7% Risk Factor improved Modification program vs Standard care after ablation Assessment post-af ablation Tomas G. Neilan et al. J Am Heart Assoc 2013;2:e

33 AF ablation Overview Generally indicated in drug-resistant, symptomatic patients ARREST AF trial Success rates Paroxysmal 60-80% Persistent 50-70% Aggressive Risk factor REducution Study for Best results in younger 2nd procedure needed patients Atrial with Fibrillation paroxysmal and Implications in 10 20% for of cases the AF and no structural Outcomes heart of Ablation disease Complication rates Major < 5% Results have progressively 281 AF ablation patients Death 0.7% Risk Factor improved Modification program vs Standard care after ablation

34 ARREST AF study AF ablation Overview Generally indicated in drug-resistant, symptomatic patients Success rates Paroxysmal 60-80% Persistent 50-70% ARREST AF trial ARREST AF study results applicable Aggressive to AF population Risk factor prior REducution to ablation Study too.. for. Best results in younger 2nd procedure needed patients Atrial with Fibrillation paroxysmal and Implications in 10 20% for of cases the AF and no structural Outcomes heart LEGACY of trial Ablation disease Complication rates Major < 5% Results have progressively 281 AF ablation patients Death 0.7% Risk Factor improved Modification program vs Standard care after ablation RFM group - - Improved weight, BP, DM, and lipids and AF recurrence

35 LEGACY trial JACC - - May, 2015 Group AF burden reduced Group 6x (p< ) 1 (135 pts) >10% BMI loss 355 patients with AF and BMI of >27 kg/m 2 Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort Group 1 and Group LA volumes and LVH reduced Group 2 (103 pts) Gradual weight loss most 3-9% effective BMI loss Membership offered in Physician-directed weight loss program Re-evaluated at one year Group 3 (117 pts) <3% BMI loss Group 1 46% without AF without med/ablation Rx!

36 AF - - PV origin Anticoagulation essential in most Cardiac monitoring enhances AF detection and survival Atrial Fibrillation 2015 Advances Medical Rx effective in some, recurrences possible Ablation results improving Lifestyle changes essential

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38 Atrial Flutter Distinctive Mechanism

39 Atrial Flutter - - Ablation targets right atrial pathway Mechanism Management Medical Therapy similar to Atrial Fibrillation including rate control and anti-arrhythmics Ablation targets Cavotricuspid Rotating circuit isthmus in or CTI with very high right atrium only success rate Typical Atrial fibrillation may later occur as Counterclockwise; underlying substrate similar Reverse typical Clockwise Anticoagulation essential in most patients similar to AF with CHA ablation 2 DS 2 - VAS C score providing guidance IVC - Tricuspid annulus ( cavotricuspid ) isthmus is the target of

40 Tachycardia-induced Cardiomyopathy Anticoagulation Carvedilol, Lisinopril 58 year old man Recent respiratory NSR illness maintained year 3-week Amiodarone PND, orthopnea, Echo palpitations EF at Lasix, Spironolactone Cardioversion Heart Failure presentation Catheter ablation Class I at 3 weeks Echo EF - Cardiac cath No CAD 3 months 50%

41 Dofetilide (Tikosyn) 1518 patients with Heart failure/lv dysfunction Three-Day admission to Initiate Rx, monitor QT interval DIAMOND-CHF Study 756 Patients - - Placebo 762 Patients - - Dofetilide

42 Dofetilide (Tikosyn) DIAMOND-CHF Study No Adverse Effect on Survival

43 Dofetilide (Tikosyn) DIAMOND-CHF Study Outcome Patients with Baseline AF

44 New Cardiovascular Horizons 2015 May 28, 2015 New Orleans, Louisiana Atrial Fibrillation New Approaches, Techniques, and Technology State of the Art Richard Abben, M D Director, Cardiac Arrhythmia Service Cardiovascular Institute of the South Associate Clinical Professor of Medicine LSU School of Medicine