AF Ablation in Patients with Heart Failure

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1 AF Ablation in Patients with Heart Failure Christian de Chillou, MD, PhD Department of Cardiology University Hospital Nancy, France 28ème Journée Internationale du Centre Cardio-Thoracique de Monaco Monaco, 4 Novembre 2016

2 Introduction - Background

3 Pathophysiological interactions between AF and HF Ling LH, et al. Nature Reviews Cardiology 2016;13:131-47

4 Prevalence of AF in selected trials of patients with HF Ling LH, et al. Nature Reviews Cardiology 2016;13:131-47

5 Atrial Fibrillation & Heart Failure: Epidemiology Framingham population 1470 patients mean follow-up = 5.6 years AF CHF = 3.3% per year CHF FA = 5.4% per year Wang TJ et al. J Circulation 2003;107:2920-5

6 Atrial Fibrillation & Heart Failure: Prognosis Framingham population 1470 participants / Initial Event : AF (n=683), CHF (n=708), AF & CHF (n=79) Mean Follow-up = 5.6 Years Wang TJ et al. J Circulation 2003;107:2920-5

7 Effect of β blockers on survival in patients with HF & AF Sinus Rhythm Group Atrial Fibrillation Group Kotecha D et al. Lancet 2014;384:

8 Rate control or Rhythm control?

9 Rate control vs. Rhythm control CHF trial : a dedicated study in patients with HF Roy D et al. N Engl J Med 2008;358:

10 The efficacy of antiarrhythmic drugs is modest to maintain sinus rhythm in patients with persistent AF 236 patients persistent AF The choice of ADDs is very limited in patients with HF: amiodarone! Van Gelder IC et al. Arch Int Med 1996;156: Carlsson J et al. J Am Coll Cardiol 2002;41:1690-6

11 Atrial Fibrillation & Heart Failure: Epidemiology 43% 34% 21% 23% 22% 23% 19% 15% First Episode Paroxysmal Persistent Permanent HF no HF p<0.001 The different types of AF at entry in the registry in relation to the presence of HF Nieuwlaat R et al. Eur Heart J 2005;26: EURO HEART SURVEY Registry

12 Survival rate in patients with AF: negative impact of AADs vs. benefit of sinus rhythm The AFFIRM Investigators N Engl J Med 2002;347: The AFFIRM Investigators Circulation 2004;109:

13 AF ablation in patients with HF 94 pts with LV dysfunction Persistent / Permanent AF =61% Long-term success w/o drugs =73% 58 pts with CHF Permanent AF =74% Long-term success w/o drugs =78% Hsu LF et al. N Engl J Med 2004;351: University Hospital Bordeaux Chen MS et al. J Am Coll Cardiol 2004;43: Cleveland Clinic, Cleveland, Ohio

14 AF ablation in patients with HF: Technical considerations

15 Recorded in 1910 W. Einthoven Medicine Nobel price award 1924

16 AF triggered by PV firing Diagram of the sites of 69 foci triggering atrial fibrillation in 45 patients. Haïssaguerre M et al. N Engl J Med 1998;339: Probability of a PV origin >95%

17 AF triggered by PV firing

18 AF triggered by PV firing RF application time : 30 to 50min

20 AF triggered by PV firing 728/min!

21 AF triggered by PV firing

22 From paroxysmal to permanent AF : atrial remodeling Paroxysmal AF Persistent AF Permanent AF Single source (PV) Multiple sources - Intensity of atrial remodeling + Focal Mechanism Diffuse Substrate Camm AJ, et al. Eur Heart J 2010;31:

23 Speed 1/20 By Courtesy of Pr. Michel Haïssaguerre

24 Persistent AF ablation of multiple rotors

25 Long-standing persistent AF ablation of multiple rotors Isochronal step = 20ms Extensive ablation of areas showing the most fragmented EGMs

26 Long-standing persistent AF ablation of multiple rotors Isochronal step = 20ms regional organisation of AF then sinus rhythm resumes

27 Balk EM, et al. J Cardiovasc Electrophysiol 2010;21: ,2% vs. 23,5%

28 Long-term single- and multiple-procedure outcome and predictors of success after catheter ablation for persistent AF Rostock T et al. Heart Rhythm 2011;8:1391-7

29 AF ablation in patients with HF Data from the literature

30 Ablation vs. Amiodarone for treatment of persistent AF in patients with CHF : the AATAC multicenter randomized trial Catheter Ablation Amiodarone Di Biase L et al. Circulation 2016;133:

31 Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

32 Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials Change in LVEF Change in Minnesota Living With Heart Failure Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

33 Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials Change in 6-minute walk test distance Change in peak oxygen consumption (VO 2 ) Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

34 Upcoming trials relating to heart failure and atrial fibrillation Kotecha D, Piccini JP. Eur Heart J 2015;36:3250-7

35 Management of AF in patients with HF

36 2016 ESC Guidelines Amiodarone withdrawal for side effects Short-term = 10-15% Long-term = 20-50% Kirchhof P et al. Eur Heart J 2016 Aug 27. pii:ehw210

37 2016 ESC Guidelines Kirchhof P et al. Eur Heart J 2016 Aug 27. pii:ehw210

38 Conclusions Patients with both AF and HF present unique diagnostic and management challenges No randomized trials has demonstrated that pharmacological rhythm control confers a reduction in mortality compared with rate control in patients with both AF and HF Studies of highly selected populations of patients with both AF and HF indicate that, in the short term, AF ablation improves symptoms of HF, functional capacity, and LVEF Randomized, controlled trials to evaluate hard clinical outcomes of AF in patients with both AF and HF are currently in progress

39 Information to patients 1) Sinus rhythm is much better than AF 2) AF ablation is much better than drugs 3) AF ablation to improve symptoms 4) Complication rate is getting lower (especially TIA/stroke) 5) More than one procedure : very likely!

In Whom and When Should Atrial Fibrillation Ablation be Considered?

In Whom and When Should Atrial Fibrillation Ablation be Considered? Christian de Chillou, MD, PhD Department of Cardiology University Hospital Nancy, France ESC 2010 Stockholm, August 30. 2010 2 In Whom?