Atrial Fibrillation Ablation in Patients with Heart Failure

Transcription

1 Atrial Fibrillation Ablation in Patients with Heart Failure Eleftherios M. Kallergis, MD, PhD, FESC Cardiology Department, Heraklion University Hospital

2 Since auricular fibrillation so often complicates very serious heart disease, its occurrence may precipitate heart failure or even death, unless successful therapy is quickly instituted Paul Dudley White

3 Atrial Fibrillation and Heart Failure : Epidemiology 22% HF pts developed AF over a mean follow-up of 4.2 years incidence rate 5.4% per year Wang T J et al. Circulation. 2003

4 Atrial Fibrillation and Heart Failure : Epidemiology AF prevalence relates with heart failure severity AF and HF have emerged as new cardiovascular epidemics Savelieva et al. Europace 2004

5 Atrial Fibrillation and Heart Failure : Epidemiology The presence of AF is associated with increased mortality in both CHF pts with preserved and impaired LV systolic function Mamas, Eur J Heart Fail 2009 and Aleong, The American Journal of Medicine 2014

6 Atrial Fibrillation and Heart Failure : A Vicious Pathophysiological Cycle Sinus Rhythm Rhythm Control

7 Atrial Fibrillation and Heart Failure Rate or Rhyth Control In HF pts with AF

8 Rhythm or Rate Control? PIAF STAF AFFIRM RACE HOT CAFE Pts F-u (mo) Age AF Persistent Persistent Persistent/ Paroxysmal Persistent/ Recurrent after ECV Persistent Therapies Am-ECV Am-Prop-Fl- ECV Am-Sot- Prop-ECV Sot-Fl-Prop- Am-ECV Am-Sot-Prop Endpoint Symptoms Comp clinical events Death Comp clinical events Comp clinical events Results No differ No differ No differ No differ No differ None of these trials demonstrated the expected superiority of the rhythm control strategy

9 Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control 58% in the rhythm control group had at least one recurrence of AF during follow-up 40% in the rate control group was not in AF during the trial AF-CHF trial NEJM 2008

10 Rhythm or Rate Control? Effects of strategies diluted by: Suboptimal maintenance of SR by rhythm control strategies Not all patients in rate control strategy have persistent AF The beneficial effects of rhythm maintenance could have been counterbalanced by: Toxicity of antiarrhythmic drugs Significantly higher rate of use of beta blockers in rate control strategy

11 Sinus Rhythm in AFFIRM was Associated with Better Survival RR = 0.54 RR = 0.47 RR = 1.50 RR = 1.41 The AFFIRM Investigators, Circulation 2004

12 Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control CHF-STAT The spontaneous conversion of AF to sinus rhythm improved the survival rate in patients with HF Deedwania, Circulation 1998

13 Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control In HF pts with AF, restoration of SR is associated with improved survival This association was even more pronounced when the time of being in SR was included in the multivariate analysis and was independent of either treatment with dofetilide or placebo DIAMOND Substudy Circulation 2001

14 Antiarrhythmic Drugs and AF If an effective method for maintaining SR with fewer adverse effects was available, it might be beneficial

15 Catheter Ablation of AF in Heart Failure Patients: Is it effective?

16 Sinus Rhythm Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure HF No HF Total pts Off AADs CA resulted in long-term restoration of SR without the use of AADs in most patients significant improvement of exercise capacity, symptoms, and quality of life Haïssaguerre et al. NEJM 2004

17 Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure Improvement in LV Function and Dimensions after Ablation in Pts WIth CHF The LVEF improved significantly regardless of the presence or absence of concurrent heart disease or rate-controlled arrhythmia Haïssaguerre et al. NEJM 2004

18 Maintenance of NSR without AADs post AF ablation in patients with HF The maintenance of SR free of AADs post ablation ranged from 50% up to 87% Amin et al. World Journal of Cardiovascular Diseases 2013

19 CAfor AF in Patients With LVSD: Systematic Review and Meta-Analysis CA resulted in significant improvement of LV function Patients with CAD seem to benefit less than pts with other underlying diseases Dagres et al. J Cardiac Fail 2011

20 Catheter Ablation Versus Rate Control in the Management of AF in Heart Failure Efficacy Safety Clinical outcome

21 Catheter Ablation Versus Rate Control in the Management of Persistent AF in Heart Failure Single procedure success was 72%, and multi-procedural success was 92% The primary end point, peak oxygen consumption significantly increased in the ablation arm compared with rate control ARC-HF trial, J Am Coll Cardiol. 2013

22 Catheter Ablation Versus Rate Control in the Management of Persistent AF in Heart Failure Secondary end point measures of quality of life and BNP were improved significantly with CA Left atrial size was reduced by ablation, while EF showed only a nonsignificant increase ARC-HF trial, J Am Coll Cardiol. 2013

23 The CAMTAF Trial CA was able to restore SR in the majority of patients with peraf improvement in left ventricular function which was evident at 1 m and was sustained up to 1 y reversal of left ventricular remodelling as evidenced by the reduction in ESV compared to the rate control group The CAMTAF Trial. Circ Arrhythm Electrophysiol. 2014

24 The CAMTAF Trial CA resulted in improved exercise capacity, BNP, NYHA class, heart failure symptoms and quality of life compared to a medical rate control strategy The CAMTAF Trial. Circ Arrhythm Electrophysiol. 2014

25 Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction Normal EF<40 Diastolic AAD free AF elimination AF control on or off AAD AF ablation in pts with diastolic dysfunction is effective with 1-year AF-free rates without and with AADs of 75% and 85% and a 5-year atrial arrhythmia-free rate of 40% Low procedural risk, LV function and QOL improvement Cha et al. Circ Arrhythm Electrophysiol. 2011

26 CA Versus Rate Control in the Management of AF in Heart Failure: Complications There are no differences in complication rates after CA, in patients with normal compared to impaired LV systolic function

27 Key Questions Specific to CA of AF in pts With HF Does catheter ablation improve mortality compared with a pharmacological rate control strategy? Is the efficacy of catheter ablation for AF dependent on the etiology of HF Will the ischemic promising results vs. nonischemic? achieved in smaller clinical trials be Are post-ablative observed improvements in larger clinical functional studies? capacity and quality of life preserved beyond 1 year? Does catheter ablation reduce HF hospitalization at 1-year and longer follow-up? Is catheter ablation cost effective in patients with HF? Is catheter ablation a viable first-line treatment of AF in patients with HF?

28 AATAC Multicenter Randomized Trial Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device 70% recurrence free average 1.4±0.6 procedures Follow up 26 ± 8 months 34% recurrence free Luigi Di Biase et al. Circulation. 2016

29 AATAC Multicenter Randomized Trial Hospitalization (%) Mortality (%) P< P< Ablation 0 Amio Ablation Follow up 26 ± 8 months Amio Luigi Di Biase et al. Circulation. 2016

30 CASTLEAF The only existing study that measures a hard primary outcome in patients who have received catheter ablation or conventional therapy for AF

31 CASTLEAF - Study Design Death from any cause or Hospitalization for worsening heart failure Marrouche NF et al. N Engl J Med. 2018

32 CASTLEAF Pulmonary Vein Isolation (98,7%) Additional lesions (51,7%) at discretion of operator Repeat ablation after blanking period (24.5)

33 AF Burden Recurrence Rate 50 % 1.3 abl procedures per treated patient Marrouche NF et al. N Engl J Med. 2018

34 Maintenance of Sinus Rhythm Marrouche NF et al. N Engl J Med. 2018

35 LVEF Change Marrouche NF et al. N Engl J Med. 2018

36 Death or Hospitalization for Heart Failure Marrouche NF et al. N Engl J Med. 2018

37 Hospitalization for Heart Failure Marrouche NF et al. N Engl J Med. 2018

38 Total Mortality Marrouche NF et al. N Engl J Med. 2018

39 Cardiovascular Mortality Marrouche NF et al. N Engl J Med. 2018

40 Cardiovascular Hospitalization Marrouche NF et al. N Engl J Med. 2018

41 Subgroup Analyses of the Primary End Point

42 Serious Adverse Events Marrouche NF et al. N Engl J Med. 2018

43 It's time to offer AF-ablation procedures at an early stage in CHF patients with AF The progressive nature of AF is partly caused by AF itself, but also reflects progression of underlying structural heart diseases There is evidence that the time course of AF stabilization in patients with structural heart disease is more rapid than in lone AF patients Early ablation could avoid AF progression

44 Before CASTLE-AF AF and HF with impaired or preserved LV function coexist with increasing prevalence increased mortality deterioration of LV function, NYHA class, exercise tolerance, and quality of life Pharmacological therapy of AF in this population is limited suboptimal efficacy and increased risk of proarrhythmia

45 After CASTLE-AF CA of AF in pts with heart failure is associated with improved all-cause mortality and fewer admissions for worsening heart failure when compared to conventional standard of care treatment CA of AF in patients with heart failure is also associated with improved cardiovascular mortality and hospitalization when compared to conventional standard of care treatment

46 After CASTLE-AF It seems reasonable to be more aggressive in offering ablation for atrial fibrillation in patients who also have congestive heart failure

47