How Should we Select Patients for Catheter Ablation? Douglas Esberg, MD, FHRS

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1 How Should we Select Patients for Catheter Ablation? Douglas Esberg, MD, FHRS November 2, 2018

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5 Atrial Flutter Typical isthmus dependent flutter Success rate ~95% Complications 1% (mostly groin complications) Coexistent Atrial Fibrillation 15-25% Ablation CURES Atrial Flutter!

5 5 Atrial Flutter Typical isthmus dependent flutter Success rate ~95% Complications 1% (mostly groin complications) Coexistent Atrial Fibrillation 15-25% Ablation CURES Atrial Flutter! CHING TAI TAI M.D. et.al., Long-Term Outcome of Radiofrequency Catheter Ablation for Typical Atrial Flutter: Risk Prediction of Recurrent Arrhythmias. J Card Electophysiology, vol 9, issue 2, 1998

6 Atrial Fibrillation 6

7 7 Ablation Targets PVI CFAE Scar homogenization Linear/Box lesions SVC Isolation Ablate to termination

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10 10 Treatment Antiarrhythmic drugs Variable response 30-50% Ablation Many small studies, few large RCTs Success 50-80% Definition of success varies Duration of follow up Method of monitoring THERE IS NO CURE FOR ATRIAL FIBRILLATION

11 11 Randomized Controlled Trials RAAFT PAF, drug vs. ablation, 70 pts, enrolled % vs. 37% AF-free RAAFT-2 PAF, drug vs. ablation, 127 pts, enrolled % vs. 28% AF-free CABANA 2204 pts, Primary Outcome: death/stroke/bleed/ca (8% vs. 9.2%) 50% vs. 30% AF-free at 5 yrs

12 First-Line AF Catheter Ablation: RAAFT-2 Natale and colleagues. JAMA 2014

13 13 Paroxysmal <7 days Persistent >7 days, <1 year Longstanding Persistent >1 year Permanent

14 Ablation Outcome: Early and Late Procedural Success 66.6% 54.1% 41.8% 51.9% 64.2% 53.1% Ganesan et al. J Am Heart Assoc 2013

15 Catheter Ablation of Persistent AF G. Hindricks 2017

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18 18 It depends upon what the meaning of the word is is -William Jefferson Clinton, 1998

19 PVI as Adjunctive Rx

20 Who to Ablate? 20

21 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Training Requirements, Surgical Ablation, and Clinical Trial Design Eduardo B. Saad, MD, PhD, FHRS

22 22 Who to Ablate? Catheter and surgical ablation of AF are well established and important treatment options for patients with AF in whom a rhythm control strategy is chosen The primary indication for performance of AF ablation is the presence of symptoms associated with AF. AF ablation is generally considered after at least one antiarrhythmic medication has been tried and proven to be ineffective or poorly tolerated. A desire to stop anticoagulation is not an appropriate indication for AF ablation. For most patients with AF who have a high stroke risk profile, anticoagulation should be continued following their ablation procedure.

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24 Impact of Catheter Ablation on Stroke Risk To date, there are no RCTs verifying the hypothesis that ablation lowers the long-term incidence of stroke or TIA. 1. The Intermountain Healthcare Database in Utah (4,212 ablated patients) 2. MarketScan Research Database (n = 805 in each group) 3. Taiwanese national health insurance claims database (846 ablated patients) 4. Swedish health registries (n = 2836 in each group) Ablation was associated with a lower incidence of ischemic stroke than in nonablated patients. Ablation-treated patients without AF recurrence had a lower incidence of ischemic strokes and TIAs compared with patients with AF recurrence or medically treated patients. It is recognized that the retrospective nature of these studies makes them prone to bias. Therefore, the above findings cannot be viewed as definitive and do not provide sufficient evidence that ablation reduces stroke risk. Instead, they reinforce the hypothesis behind studies such as the CABANA trial or the EAST trial, which will provide more definitive evidence.

25 Impact of Catheter Ablation on Stroke Risk Long-Term Survival Free of CVA Event-Free Survival AF, with ablation No AF 0.90 Log rank P < AF, without ablation Days to CVA

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27 Randomized Controlled Trial on CA of AF in HF: AATAC Di Biase et al. Circulation 2016

28 Randomized Controlled Trial on CA of AF in HF: AATAC Di Biase et al. Circulation 2016

29 363 pts Symptomatic paroxysmal or persistent AF Didn t respond to AAD randomized to CA vs. medical therapy 29

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31 31 What Groups May Benefit? Symptomatic Paroxysmal, failed at least one AAD Heart failure (HFrEF or HFpEF) Symptomatic Paroxysmal, first line Symptomatic Persistent Symptomatic Longstanding Persistent Asymptomatic associated with tachy-mediated cardiomyopathy Young and asymptomatic

Rebuttal. Jerónimo Farré MD 2010

Rebuttal. Jerónimo Farré MD 2010 Rebuttal 1.We do not know what are the types of AF in which ablation is worthless or most effective 2.Waiting implies to consider the ablation at an older age and when the duration of the history of AF