AF Ablation in 2015 Why, Who, What and How? Steve Wilton ACC Rockies, Banff March 10, 2015
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1 AF Ablation in 2015 Why, Who, What and How? Steve Wilton ACC Rockies, Banff March 10, 2015
2 Disclosures Research grant: St. Jude medical Speaking: Boehringer-Ingelheim Consulting: Arca Biopharma
3 Learning Objectives Why? Indications for AF ablation Who? Review patient selection What? Review ablation strategies How? Explore new technologies
4 The AF Epidemic Framingham Lloyd-Jones, Circulation, 2004
5 Why? Goals of AF ablation Reduce AF symptoms (improve QoL) Eliminate antiarrhythmic drugs Decrease stroke risk? Prevent/reduce heart failure? Reduce hospitalizations? Improve survival? Avoid anticoagulation?
6 CCS Rate -Rhythm control algorithm Verma, CJC, 2015
7 Indications - ACC/AHA AF Guideline Symptomatic patients with Class Level Paroxysmal AF, failed 1 antiarrhythmic drug I A Paroxysmal AF, first line IIa B Persistent AF <1yr, failed 1 antiarrhythmic IIa A Persistent AF 1 yr, failed 1 antiarrhythmic IIb B January, Circ, 2014
8 AF Ablation first line? 1.0 Cumulative Hazard Rate 0.8 Antiarrhythmic drug 0.6 Radiofrequency catheter ablation HR, 0.56, 95% CI, , P = Follow-up Since Randomization, d RAAFT-2, Morillo, JAMA, 2014
9 Patient Selection role of CHADS2 Chao, Heart Rhythm, 2011
10 Imaging for patient selection Marrouche, JAMA, 2014
11 Imaging for patient selection Marrouche, JAMA, 2014
12 Role of Lifestyle Modification BMI 27, 1 risk factor Pre-ablation opt-in Weight loss (10%) BP control Lipid control OSA assessment/tx ARREST AF Cohort: Sanders, JACC, 2014
13 What? Calkins, HRS Consensus, 2012
14 What? Calkins, HRS Consensus, 2012
15 PAF: Circumferential PVI
16 Paroxysmal vs. Persistent AF PAF Triggers & Drivers (PVs) Ps AF Abnormal Atrial Tissue Disease Progression Electrical Remodeling Structural Remodeling Fibrosis Inflammation
17 Stepwise Approach for Persistent AF 1. PV Isolation 2. Defragmentation 3. Linear Ablation LAA RSPV LSPV RIPV Isolation LIPV CS Local EGM organization Ø Roof Ø Mitral MA Conduction block Endpoint: Termination of AF (70-85%) Hocini M et al. J Am Coll Cardiol. 2010;55: O Neill M et al. Eur Heart J. 2009;30: Haissaguerre M et al. J Cardiovasc Electrophysiol. 2005;16:
18 Stepwise Ablation: Long Term Multiple Procedure Results (median 2) Scherr, Circ AE, 2015
19 How? Technological Advances 1. Use the Force! Catheter tissue contact is critical Standard methods are all flawed Catheter feel Fluoro EGM size Impedance change
20
21 2. Freeze it: Cryoballoon Good tissue contact May reduce procedure time Results similar to radiofrequency Phrenic nerve palsy risk? Costs
22 3. Get smart: AF mapping Rotors: putative drivers of AF Previously not proven to exist in humans Narayan, JACC, 2012
23 Unanswered Questions Does AF ablation influence prognosis? CABANA, RAFT AF Does risk factor control improve outcomes? SMAC AF, others Can we stop OAC after successful ablation? OCEAN
24 Key messages Why? Primarily symptom control Ongoing trials will address prognosis Who? Patient selection evolving Don t forget lifestyle modification What? PVI for Paroxysmal Optimal strategy in Persistent AF unclear How? Rapid technological advances continue
25 Thanks!
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