Rebuttal. Jerónimo Farré MD 2010

Transcription

1 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 might be too long 3.Ongoing trials will establish better what the role is of an earlier intervention in patients with AF with and without LV dysfunction or heart failure

2 AF not a single entity AF & ion chanel disorders AF familial AF & sports AF & WPW Adrenergic AF Vagal AF AF & hyperthyroidism AF & hypertension AF and inflammation and oxidative stress AF and tobacco AF & ischemic HD AF & HCM AF & DCM Lone AF [true lone AF] Rheumatic AF AF and nonrheumatic VHD

3 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 might be too long 3.Ongoing trials will establish better what the role is of an earlier intervention in patients with AF with and without LV dysfunction or heart failure

4 Duration of AF and successful ablation Michel Haissaguerre J Am Coll Cardiol 2009;54: In multivariate analysis, the surface ECG AFCL and the AF duration predicted clinical success of persistent AF ablation (p<0.01 and p<0.05, respectively)

5 Canadian Registry of AF (CARAF) 757 patients from 6 Canadian centers at the time of their first PAF Median follow-up 8.0 years (2 days-11.1 years) Probability of progression to CAF by 1 yr 8.6% by 5 yrs 24.7% By 5 years, the probability of documented recurrence of any AF (chronic or paroxysmal) was 63.2%. Am Heart J 2005;149: Risk factors for development of CAF 1. increasing age 2. significant aortic stenosis 3. significant mitral regurgitation 4. left atrial enlargement 5. cardiomyopathy

6 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 might be too long 3.Ongoing trials will establish better what the role is of an earlier intervention in patients with AF with and without LV dysfunction or heart failure

7 The RAAFT Study First Line Radiofrequency Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation Treatment currently recruiting participants Symptomatic, recurrent paroxysmal AF lasting > 30 seconds (at least 4 episodes within the last 6 months). At least one episode documented by Holter, 12-lead ECG, event monitor or rhythm strip. Primary Outcome Primary Efficacy: Primary Safety: Ablation Arm: AAD Arm: time to first ECG documented recurrence of symptomatic AF lasting >30 seconds >70% PV stenosis at 3, 12 months, CVA, TIA, pericarditis, myocardial infarction, diaphragmatic paralysis, procedural complication requiring intervention and death. TdP, syncope, bradycardia requiring PM, other events leading to drug discontinuation, Bleeding complications associated with OAC Estimated Enrollment: 400 Study Start Date: August 2006 Completion Date: December 2009 Pilot with 70 pts JAMA. 2005; 293:

8 CABANA trial Catheter Ablation Versus Anti-Arrhythmic Drug Therapy for AF This study is currently recruiting participants Primary outcome: catheter ablation for eliminating AF is superior to either rate or rhythm control drugs for reducing total mortality in patients with untreated or incompletely treated AF documented AF episodes 1 hour in duration ( 2 episodes over 4 months or 1 episode lasting >1 week) 65 yrs of age, or <65 yrs with one or more risk factors for stroke (Hypertension*, Diabetes, Congestive heart failure, Prior stroke or TIA, LA size 5.0 cm, or EF 35) * if hypertension a second risk factor or LV hypertrophy is required Estimated Enrollment: 3000 Study Start Date: August 2009 Completion Date: September 2015 Primary Completion Date: March 2015

9 CASTLE-AF study Catheter Ablation Versus Standard Conventional Treatment in Patients With Left Ventricular Dysfunction and Atrial Fibrillation This study is currently recruiting participants Symptomatic paroxysmal or persistent AF in pts in whom amiodarone has failed or cannot be taken, with LVEF 35% and NYHA II Dual chamber ICD with Home Monitoring capabilities already implanted Primary Outcome Measures: All-cause mortality or worsening heart failure requiring unplanned hospitalization [ Time Frame: 5 years ] Estimated Enrollment: 420 Study Start Date: January 2008 Completion Date: January 2013 Primary Completion Date: January 2013

10 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 might be too long 3.Ongoing trials will establish better what the role is of an earlier intervention in patients with AF with and without LV dysfunction or heart failure Time will tell and don t forget that we must still improve the ablation techniques in AF