Atrial Fibrillation and Heart Failure
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1 Date Clinical Title Atrial Fibrillation and Heart Failure Raul Weiss MD, FAHA, FACC, FHRS and CCDS Director, Electrophysiology Fellowship Program Professor of Medicine The Ohio State University Wexner Medical Center C. p. Lao Disclosures Educational and Research support from Boston Scientific, Medtronic, Abbot Medical, Biotronik and Biosense Webster Advisory honoraria from Biosense Webster, Biotronik, Catheter Robotic, Abbot Medical and Boston Scientific Speaker honoraria from Biotronik, Boston Scientific, St Abbot Medical and Biosense Webster 1
2 Prevalence of AF in Several Major HF Trials Maisel Am J Cardiol 2003;91(suppl):2D 8D The Problem and the Possible Solution of Rhythm Control in Patients with HF and AF Antiarrhythmic options are scarce in patients with heart failure and carry risks of toxicity Improved outcomes associated with catheter ablation raises the possibility of more efficacious therapies in the future 2
3 The Decision to Pursue Atrial Fibrillation Ablation Depends on Several Factors Type or pattern of atrial fibrillation Left atrial size Severity of symptoms Associated cardiovascular disease (presence or absence of systolic or diatolic dysfunction) The patient s previous history of treatment Estimated risk of complications Patient preference Calkins H, Kuck KH, Cappato R, et al HRS/EHRA/ECAS expert consensus Heart Rhythm 2012; 9: Rate vs. Rhythm Control of Atrial Fibrillation in Patients with Heart Failure 3
4 Forest Plot Comparing Rate and Rhythm Control for Total Mortality in Patients With AF And HF 4
5 Forest Plot Comparing Rate And Rhythm Control For Hospitalizations In Patients With AF And HF Forest Plot Comparing Rate And Rhythm Control For Stroke/Thromboembolic Events In Patients With AF And HF 5
6 Key Results From Randomized Clinical Trials Of AF Ablation Compared With Antiarrhythmic Drugs Piccini et al Lancet 2016; 388: Halabi et. al. J Am Coll Cardiol EP 2015;1:
7 Intervention Characteristic Halabi et. al. J Am Coll Cardiol EP 2015;1:200 9 Changes in Outcome: Change in LVEF Halabi et. al. J Am Coll Cardiol EP 2015;1:
8 Changes in Outcome: Change in Minnesota Living With Heart Failure (MLWHF) Halabi et. al. J Am Coll Cardiol EP 2015;1:200 9 Changes in Outcome: Change in 6- MWT Distance Halabi et. al. J Am Coll Cardiol EP 2015;1:
9 Changes in Outcome: Change in Peak Oxygen Consumption (VO2) Halabi et. al. J Am Coll Cardiol EP 2015;1:200 9 Adverse Events Halabi et. al. J Am Coll Cardiol EP 2015;1:
10 Ganesan Heart, Lung and Circulation (2015) 24, Primary Success of AF RFA 73% 17% 56% Ganesan Heart, Lung and Circulation (2015) 24,
11 Overall Success of AF RFA 82% Ganesan Heart, Lung and Circulation (2015) 24, LVEF Change With AF RFA 13% Ganesan Heart, Lung and Circulation (2015) 24,
12 Rate of Serious Adverse Events in Patients With LVSD Patients Undergoing Catheter Ablation of AF 5.5% Ganesan Heart, Lung and Circulation (2015) 24, Prabhu, S. et al JACC 2017;70(16):
13 Change in Absolute LVEF from Baseline According to Treatment ARM Prabhu, S. et al JACC 2017;70(16): Change in Absolute LVEF from Baseline According to LGE Prabhu, S. et al JACC 2017;70(16):
14 Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device Results From the AATAC Multicenter Randomized Trial Baseline Characteristics of Study Population Luigi Di Biase et al. Circulation. 2016;133: Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device Results From the AATAC Multicenter Randomized Trial 70% 30% Persistent AF CRTd/Dual-Chamber ICD EF <41% NYHA II/III Unplanned Hospitalization Group-1 31% Group-2 57% logrank P< RRR of 45% Deaths Group-1 8% and 18% group-2; log-rank P=0.037 with 56% RRR on mortality (relative risk, 0.44; 95% CI, 0.20 to 0.96; NNT10 patients). Luigi Di Biase et al. Circulation. 2016;133:
15 CASTLE-AF Recently presented at ESC PRIMARY ENDPOINT The primary study endpoint was the composite of allcause death or unplanned hospitalization due to worsening of heart failure, whichever came first. CASTLE-AF SECONDARY ENDPOINTS All-cause mortality Worsening of HF requiring unplanned hospitalization Cerebrovascular accidents Cardiovascular mortality Unplanned hospitalization due to cardiovascular reasons All-cause hospitalization Quality of life: MLHF and EuroQoL EQ-5D Exercise tolerance ( six-minute walk test) Number of delivered ICD shocks, and ATPs (appropriate/inappropriate) Time to first ICD shock, and time to first ATP Number of device-detected VT/VF AF burden: cumulative duration of AF episodes AF-free interval: time to first AF recurrence after 3 months blanking period post ablation Left ventricular ejection fraction (EF) 15
16 CASTLE-AF: PRIMARY ENDPOINT The composite primary endpoint of allcause mortality or hospitalization due to worsening of HF was significantly reduced in the catheter ablation group versus the control group (HR: 0.62; 95% CI: ; p=0.007). CASTLE-AF: PRIMARY ENDPOINT The composite primary endpoint of allcause mortality or hospitalization due to worsening of HF was significantly reduced in the catheter ablation group versus the control group (HR: 0.62; 95% CI: ; p=0.007). 38% Reduction 16
17 CASTLE-AF MAJOR SECONDARY ENDPOINTS All-cause mortality was significantly reduced in the catheter ablation group versus the control group (HR: 0.53; 95% CI: ; p=0.011). Hospitalizations due to worsening of HF were significantly reduced in the catheter ablation group versus the control group (HR: 0.56; 95% CI: ; p=0.004) Conclusions Rhythm control has no benefit compare Rate control in patients with decrease LVEF Atrial Fibrillation Ablation is superior to medical rate control in patients with decrease LVEF 17
18 Thank you! 18
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