Scompenso cardiaco e F A : ruolo della ablazione transcatetere. Prof. Fiorenzo Gaita
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1 Scompenso cardiaco e F A : ruolo della ablazione transcatetere Prof. Fiorenzo Gaita
2 Patients with atrial fibrillation (%) Prevalence of AF in HF Trials % NYHA III-IV NYHA IV 40 NYHA II-III NYHA I-II 10 0
3 Heart failure and atrial fibrillation Triggered activity Heterogeneous conduction Atrial fibrosis Atrial stretch Pressure and volume overload Atrial fibrillation Heart failure Fast ventricular rate Irregular cycles Loss of atrial contraction Mitral and tricuspid regurgitation
4 Heart failure and atrial fibrillation Triggered activity Heterogeneous conduction Atrial fibrosis Atrial stretch Pressure and volume overload Atrial fibrillation Heart failure Fast ventricular rate Irregular cycles Loss of atrial contraction Mitral and tricuspid regurgitation
5 AF in pts with HF increases the risk of death In the VEST study, AF caused an increase of 2.3 times the risk of death in patients with heart failure. (Konety, AHA 1998) In the AMIOVIRT study, AF resulted an independent risk factor for mortality (RR 4) in pts with CHF. (Strickberger, J Am Coll Cardiol 2004) In the SOLVD study, AF was an independent risk factor for mortality (RR 1.34) and progression of CHF (RR 1.42). (Vermes, Circulation 2003)
6 Heart Failure therapy: aims Symptoms relief and exercise tolerance Reduction of HF-related major morbidity Reduction of mortality
7 Survival (%) Prospective, multi-center, randomized, double blind Placebo vs Amiodarone 667 pts with CHF NYHA II/IV EF 40% CHF-STAT Sub-study 564 (85%) in SR 103 (15%) with AF 33 (6%) New onset of AF at 1 year: pts in Amiodarone pts in Placebo % 4% Amiodarone Placebo 11/268 (4%) 22/296 (8%) p = Converted pts n = 16 n = 35 Non converted pts The 0 maintenance of sinus rhythm was associated to a better prognosis (wks) Circulation 1998; 98: 2574
8 RHYTHM CONTROL ATRIAL FIBRILLATION GUIDELINES HEART FAILURE AMIODARONE DOFETILIDE TC ABLATION 2006 ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation
9 Dedicated invasive atrial fibrillation options in patients with heart failure AV node ablation + RV pacing AV node ablation + CRT Direct AF ablation
10 AVJ ABLATION + BVP vs Ph therapy MILOS study 243 pts with permanent AF LVEF < 35%, QRS > 120 ms, NYHA > II 118 AV ablation + BVP ph therapy Follow-up 34 months Gasparini et al. Eur Heart J 2008
11 SURVIVAL Gasparini et al. Eur Heart J 2008
12 Heart failure and atrial fibrillation AV NODE ABLATION+PACING Triggered activity Heterogeneous conduction Atrial fibrosis Atrial stretch Pressure and volume overload Atrial fibrillation Heart failure Fast ventricular rate Irregular cycles Loss of atrial contraction Mitral and tricuspid regurgitation
13 Transcatheter Atrial Fibrillation Ablation in patients with Heart Failure 58 patients Parox AF 9% Pers AF 91% 12 months f-up Ablation protocol 100% PVI 91% PVI+LLs 78% remained in sinus rhythm in 50% of the cases at least 1 redo procedure Hsu, L.-F. et al. N Engl J Med 2004;351:2373
14 Improvement of NYHA class and LV function after AF Ablation in Patients with Congestive Heart Failure NYHA Class PRE-ABLATION POST-ABLATION 2.3 ± ± 0.5 LV Ejection fraction EF increase 21 13% Hsu, L.-F. et al. N Engl J Med 2004;351:2373
15 Khan M et al; NEJM pts PVI ablation 81 pts 40 pts PABA CHF AV node ablation and Biv pacing
16 PVI improved functional capacity (6-minute walk test) and QOL Distance increase 71 m Improvement by 26% QOL Distance increase 16 m Improvement by 6% NEJM 2008; 359 (17):
17 PVs ISOLATION EF improved in 76% of patients Improvement in EF by 8±8% AV-node ablation+biv Decrease in EF by 1±4% EF improved in only 25% of pts Khan M et al; NEJM 2008
18 RHYTHM CONTROL 2006 AF GUIDELINES 2012 AF GUIDELINES HEART FAILURE HEART FAILURE Yes No AMIODARONE DOFETILIDE Due to AF Yes No Dronedaron/ Sotalol Patient choice TC ABLATION TC ABLATION AMIODARONE ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation ESC 2012 Guidelines for the Management of Patients With Atrial Fibrillation
19 Patients with atrial fibrillation (%) Prevalence of AF in HF Trials % NYHA III-IV NYHA IV 40 NYHA II-III NYHA I-II 10 0
20 # of AF ablation studies from 2004 to 2014 # of AF ablation and HF > AF ablation AF ablation and HF # of studies (Pubmed search)
21 AF ablation studies in patients with HF Author, Year (Ref) N. pts F-U Success Redo Success months single (%) (%) final (%) LVEF (%) Chen Hsu Tondo Gentlesk Nademanee Lutomsky De Potter Cha Total: % Anselmino Calvo Nedios Bunch Khan MacDonald Jones Hunter %
22 Multicenter meta-analysis - 25 studies, 1,838 patients from 9 countries and 3 continents - direct contact whit each center will published long-term data
23 Periprocedural efficacy and complications Mean follow-up: 24 (18-48) months 40% (33-50) 60% (54-67) after redos in 32% (25-38) No death (out of 1838 patients) 21 thromboembolic events TIA/stroke (1.14%) 12 pericardial tamponade (0.65%)
24 Impact on Symptoms (NYHA class) Baseline Follow up after ablation after ablation 37 63
25 Impact on Left Ventricular Function Baseline Study end (after ablation) Study end
26 Patients with LVEF<35% with indication for ICD in primary prevention Baseline Baseline 459 Study end Study end (after ablation) at baseline reduced to 183 after ablation Avoid ICD implantation with RRR 60%
27 AF ablation protocol in patients with HF PVI only Author, Year PVI (%) LLs (%) CFAE (%) Chen Hsu Tondo Gentlesk Nademanee Atrial Linear Lines CFAEs De Potter 2010 Cha Anselmino Nedios Khan MacDonald Jones Hunter
28 AF ablation in HF our Institution s approach Parox AF Pers >6m or long-standing AF LA volume <100 ml YES Antral PVI NO Antral PVI + Linear lines and CFAEs
29 Pts in SR without drugs Surgical ablation in pts with structural heart disease long-standing AF, and enlarged left atrium U 7 PV PV 105 pts (3 groups of 35 pts) Gaita et al, Circulation 2005
30 What are the results at more than 10-year follow-up? 73% of pts in sinus rhythm 81% of patients with complete 43% with incomplete scheme Gaita et al, Ann Thorac Surg 2013
31 Persistent AF, ICD or CRT, NYHA II to III, EF <40% Catheter ablation for AF (group 1, n=102) Amiodarone (group 2, n=101). 71% 34% Catheter ablation of AF is superior to Amiodarone in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF. Di Biase et al Circulation 2016;133:
32
33 Rhythm control in heart failure 2012 ESC Guidelines 2016 ESC Guidelines Heart failure AMIODARONE (I B) DOFETILIDE (I B) Catheter Ablation (IIb B) Jones JACC 2013; Anselmino Circ AE 2014; Ganesan Heart Lung Circ 2015; Khan NEJM 2008; Al Halabi JACC CE 2015; Di Biase Circ 2016; Hunter Circ AE 2014; MacDonald Heart 2011
34 Conclusions Rhythm control by AF ablation is under recommended although it achieves an arrhythmia freedom of about 60-70% Rhythm control by AF ablation is superior to pharmacological Rx and has been shown to improve quality of life, LVEF, and to reduce ICD indications and what about mortality?
35 Presented on 27 th August at the ESC Congress 2017 in Barcelona
36 Survival Probability Relative Risk Reduction:44% Presented on 27 th August at the ESC Congress 2017 in Barcelona
37 Conclusions Rhythm control by AF ablation is under recommended although it achieves an arrhythmia freedom of about 60-70% Rhythm control by AF ablation is superior to pharmacological Rx and has been shown to improve quality of life, LVEF, and to reduce ICD indications and MORTALITY To achieve the best results AF ablation should be recommended at an early stage In pts with increased LA volume and/or persistent AF, ablation protocol needs to be more extensive than PVI alone
38 Thank you for your attention!
39 Recommendations for initial management of a rapid ventricular rate in patients with heart failure and atrial fibrillation in the acute or chronic setting 2016
40 Recommendations for a rhythm control management strategy in patients with atrial fibrillation, symptomatic heart failure (NYHA Class II-IV) and left ventricular systolic dysfunction and no evidence of acute decompensation 2016
41 Recommendations for the prevention of thrombo-embolism in patients with symptomatic heart failure(nyha Class II-IV) and paroxysmal or persistent/permanent atrial fibrillation 2016
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