ΚΑΤΑΛΥΣΗ ΚΟΛΠΙΚΗΣ ΜΑΡΜΑΡΥΓΗΣ. ΥΠΕΡ. Michalis Efremidis MD Second Department of Cardiology Evangelismos General Hospital

Transcription

1 ΚΑΤΑΛΥΣΗ ΚΟΛΠΙΚΗΣ ΜΑΡΜΑΡΥΓΗΣ. ΥΠΕΡ. Michalis Efremidis MD Second Department of Cardiology Evangelismos General Hospital

2 Rate control versus Rhythm control for Atrial Fibrillation AFFIRM N Engl J Med 2002;347:

3 Adverse Events of AADs AFFIRM N Engl J Med 2002;347:

4 Adverse Events of AADs AFFIRM N Engl J Med 2002;347:

5 Atrial Fibrillation recurrence in patients with long-lasting atrial fibrillation 49% of the pts were in sinus rhythm M. Efremidis, Can J Cardiol 2009;29:119-24

6 Indications for Catheter AF Ablation Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF (paroxysmal or persistent) in symptomatic patients. Symptomatic AF refractory or intolerant to at least one Class 1 or 3 AAD (Class IIa, level of evidence A and B respectively). European Heart Journal 2010: ESC

7 Antiarrhythmic Drugs or Catheter Ablation?

8 Radiofrequency Ablation vs Antiarrhythmic Drugs as Firstline Treatment of Symptomatic Atrial Fibrillation ADT: Flecainide-Propafenone-Sotalol O. Wazni, JAMA 2005;293:

9 Radiofrequency Ablation vs Antiarrhythmic Drugs as Firstline Treatment of Symptomatic Atrial Fibrillation 70% 60% 63% 50% 40% 30% A.FIB Recurrence 20% 10% 0% 13% PVI ADT O. Wazni, JAMA 2005;293:

10 Radiofrequency Ablation vs Antiarrhythmic Drugs as Firstline Treatment of Symptomatic Atrial Fibrillation 60% 50% 54% 40% 30% 20% Hospitalization 10% 0% 9% PVI ADT O. Wazni, JAMA 2005;293:

11 Radiofrequency Ablation vs Antiarrhythmic Drugs as Firstline Treatment of Symptomatic Atrial Fibrillation O. Wazni, JAMA 2005;293:

12 The APAF Study ADT: Amiodarone Flecainide Sotalol C. Pappone, J Am Coll Cardiol 2006;48:

13 The APAF Study CPVA ADT C. Pappone, J Am Coll Cardiol 2006;48:

14 Conclusions from the APAF Study 86% of pts randomized to CPVA were AT-free at the end of follow-up. 22% of pts randomized to ADT were AT-free at the end of follow-up (p<0.001). CPVA was associated with fewer cardiovascular hospitalizations (p<0.01) 1 TIA and 1 pericardial effusion occurred in the CPVA group. Side effects of ADT were observed in 23 pts. C. Pappone, J Am Coll Cardiol 2006;48:

15 4A Study P. Jaïs,Circulation. 2008;118:

16 COST

17 Cost Comparison of Ablation Versus Antiarrhythmic Drugs As First-Line Therapy for Atrial Fibrillation: An Economic Evaluation of the RAAFT Pilot Study Y. Khaykin, J Cardiovasc Electrophysiol 2008; :1-6

18 Complications

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20 Stroke or TIA during follow-up in pts randomized to Ablation versus AADs.

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22 Survival and EF Benefit in SR pts

23 Stroke Rate

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26 Fluoroscopy Issue

27 A 49-year-old man. 4-year history of frequent episodes of symptomatic drug refractory paroxysmal atrial fibrillation. Left ventricular ejection fraction and left atrial diameter were normal. PAF was refractory to propafenone and sotalol.

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32 LSPV LOAD

33 LSPV POT DELAY

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35 LSPV ISOLATION

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38 CFAE

39 RSPV ISOLATION

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42 Fluoroscopy Issue: 5min and 32 sec!

43 Evangelismos Hospital experience 126 pts underwent a SINGLE AF ablation procedure during the last 17 months 65% males, mean age: 57 ± 10.4 years mean AF duration: 4.5 ± 3.7 years five pts with systolic HF (LVEF<45%) and two pts with hypertrophic cardiomyopathy two major complications (0.8%) (one tamponade treated with drainage and one transient stroke)

44 Evangelismos Hospital experience 66.7% 1: paroxysmal AF 30.6% 2: persistent AF 3: long-standing AF 2.7% AF TYPE

45 Evangelismos Hospital experience Sinus rhythm AF/AT recurrence after a mean follow-up period of 10.3 ± 4.1 months, 68.2% of pts are in SR without any AAs ONLY FOUR pts suffered ATs following AF ablation!!! 4 out of 6 pts with organic heart disease are in SR

46 SR in Paroxysmal and Persistent AF

47 Conclusions In patients with paroxysmal and persistent AF and structurally normal hearts, ablation reduced the risk of AF recurrence at 1 year by 65% compared with ADT. These trials were conducted in a few high volume centers, with expert operators performing the ablation procedure that may explain the high success rate and the low complications rate of the ablation procedure. Even though the results of the systematic review favor ablation therapy, large, well-designed, multicenter clinical trials are needed to confirm the efficacy and safety of AF ablation. G. Nair, J Cardiovasc Electrophysiol 2008; 1-7