Catheter Ablation for AF: Patients, Procedures, Outcomes

Transcription

1 Catheter Ablation for AF: Patients, Procedures, Outcomes John Sapp Director Heart Rhythm, QEII Health Sciences Centre Professor of Medicine, Dalhousie University

2 Atrial Fibrillation Atrial Fibrillation is a pain in the rear. What makes it so difficult?

3 Goals of Care? Live longer and / or Live better

4 How can AF hurt your patients? Symptoms Stroke/Thromboembolism Tachycardia-induced cardiomyopathy

5 The indication for rhythm control is inadequate symptom relief with rate control

6 How to Pick Rhythm Control The main goal is symptomatic control

7 Which one is better? How To Choose Rate Vs Rhythm Control? Liparus Weevil Pissodes pini Weevil

8 The Devil you know? Rate Control Beta-blockers Ca ++ Channel Blockers Digitalis Rhythm Control AF Ablation Amiodarone, Sotalol, Flecainide, Propafenone, Dofetilide, Dronedarone

9 Young patients? Athletes? Resting Bradycardia??

10 How to rate control Beta-blockers Verapamil / Diltiazem Digoxin? Not dronedarone Sometimes pacemaker to permit drug therapy Rarely AVN ablation

11 How to Rate Control Target resting HR < 100 Sometimes a treadmill test or loop recorder is informative Pill in the pocket rate control and anticoagulation?

12 Rhythm Control Special cases for rhythm control: Heart failure? Young age Highly symptomatic Resting bradycardia / Athletes

13 Sotalol Rhythm Control Avoid in elderly women, use of diuretic, renal dysfunction, hypokalemia, prolonged QT I start at bid not higher than 160 bid Flecainide Avoid in patients with ventricular scar I start at 50 mg bid, sometimes 100 bid, rarely 150bid Propafenone Avoid in patients with ventricular scar I start at 150 bid-tid, rarely 300 tid

14 Rhythm Control Sotalol: Monitor renal function over time, check QT c interval intermittently, concern if >470, reduce dose if >500 Flecainide: Watch for side-effects QRS widening, other Propafenone: Watch for side-effects QRS widening, other

15 Rhythm Control With Flecainide / Propafenone, I always use an AV node blocking agent

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17 Catheter Ablation for AF Triggers Substrate

18 Who Should Have Ablation?

19 Risks 4.7% Complications 1.5% vascular 1% Perforation/Tamponade 1% Stroke/TIA Rarer Complications Pulmonary vein stenosis Phrenic nerve injury Atrio-esophageal fistula / Death

20 Redo Rates Seems to be changing Was approximately 1 in 3 Moving closer to 1 in 4-5.

21 Ablation Procedure

22 Ablation Techniques Radiofrequency Ablation Double trans-septal puncture Point-by-point ablation lesion delivery encircling the pulmonary veins and electrically isolating them

23 Andrade et al. CJC 2014; 30 S431-S441

24 Contact Force Sensing Catheters

25 Reddy et al. Circulation Sep 2015 TOCCASTAR

26 Recurrence at areas of low force < 10g

27 CryoAblation Liquid-Nitrogencooled balloon Advanced across interatrial septum, and inflated in pulmonary venous ostia

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30 STOP-AF Trial: Cryoablation

31 Catheter Ablation for Persistent AF Patients with persistent AF have lower success rates with catheter ablation than paroxysmal patients

32 Ablation for Persistent AF

33 Trials to come Comparisons of Cryoablation against RF ablation Comparison of cryoablation against antiarrhythmic drug therapy as an early intervention Comparison of AF Ablation versus drug therapy with clinical endpoints

34 Longer Term Outcomes Most recurrences occur within the first year after ablation Late recurrences: 87% 1 year, 81% at 2 years, 63% at 5 years 85% at 3 years, 75% at 5 years Focus still remains on ablation to control AF, not necessarily a cure

35 AF Ablation in Heart Failure LVEF LV Fractional Shortening LVEDD LVESD Hsu, NEJM 2004

36 Freedom from AF after AF ablation in patients with LV dysfunction Hunter (N=26) MacDonald (N=22) De Potter (N=36) Choi (N=15) Efremids (N=13) Lutomsky (N=18) Khan (N=41) Gentlesk (N=67) Chen (N=94) Hsu (N=58) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% AF Free post-ablation

37 RAFT-AF Hypotheses Catheter ablation-based AF rhythm control as compared with rate control in patients with HF of either impaired LV function (LVEF 45%) or preserved LV function (LVEF > 45%) will reduce allcause mortality or HF hospitalization Key Inclusion Criteria: High burden AF paroxysmal, persistent, long-term persistent NYHA class II or III HF Increased NT-proBNP/BNP Intervention: Rhythm control arm: Catheter ablation ± AAD Rate control arm: Rest HR<80; 6MW HR <110

38 Conclusions Rhythm control is still directed at symptoms First-line therapy is still usually antiarrhythmic drug therapy I think new technology is improving the single-procedure success rate New trials will help us know best technology for ablation, and role for ablation in heart failure patients with AF

39 Conclusions AF Ablation works best for patients with: Paroxysmal atrial fibrillation Normal hearts Less appropriate for Very elderly Longstanding persistent AF Diseased atria, size > 50 mm