Post-ablation Management: Drug therapy, Anticoagulation and long-term Monitoring

Transcription

1 Catheter Ablation of Atrial Fibrillation: State of the Art Post-ablation Management: Drug therapy, Anticoagulation and long-term Monitoring Dipen Shah Service de Cardiologie Hospital Cantonal de Genève ESC 2011, Paris August 29th, 2011

2 Disclosures Consultant, Research Support, or Honoraria Biosense Webster, St. Jude, Medtronic, Endosense Stock Options Endosense

3 40 yrs, M, Rheumatic Mitral stenosis, Post BMV, Persistent AF PVI+Atrial Substrate Ablation

4 5 months later..flutter 6 Flutter 7 Atrial Tachycardia 5

5 Final Result

6 Situs Inversus & Persistent AF

7 ASD & Chronic AF

8 Hypertrophic Cardiomyopathy & Persistent AF Typical Flutter LA Flutter (Peri LPV)

9 Post-Ablation Management Follow-up Early: Puncture site Anticoagulation Fluid overload Symptomatic One Month: Anticoagulation Rhythm monitoring 3 Months: PAF*- Withdraw anticoagulation Rhythm monitoring Echocardiography Stress test 6-12 Months: Rhythm monitoring Pers AF*- Withdraw anticoagulation Specific issues: Pericarditic syndrome Early non-sustained/ persistent arrhythmias Late arrhythmias Anticoagulation withdrawal Hemodynamic assessment

10 Rhythm Monitoring Routine 12 lead ECG 1, 2 or 7 day Holters Event recorders Trans-telephonic monitoring S/c Implantable loop recorders PM/Device monitoring Distinguishing flutter from Afib Recognising typical flutter 7 day Holter: greater sensitivity Symptom correlation, no burden info No burden info, symptom correlation+ Limited memory: limited burden info; low specificity Limited applicability

11 Implantable Sub-cut Recorders Single precordial lead only Limited memory Poor atrial activity resolution AF detection based on R-R interval Lorenz plot

12 Implantable Loop Recorders for AF Causes of AF mis-detection: Myopotentials/noise T-wave over-sensing Frequent VPCs, APCs R-wave undersensing Effect of software update: AF misdetection to 44% Non-diagnostic interrogations to 16% No difference in AF detection vs. 7 day Holter 31% vs 24%, p=0.125 C. Eitel et al., Europace (2011) 13,

13 PM/Intra-cardiac device monitoring Limited applicability Myopotential/noise interference reduced: optimum sensitivity and specificity Possible difficulty distinguishing flutter from fibrillation Depending upon software, may be ideal for determining AF burden Steven et al, Eur Hrt J: 29: , 2008

14 Anti-Arrhythmic Drugs Aim: To suppress or control arrhythmias No effect on eventual recurrence Questionable arrhythmia control Side-effects or intolerance Complicates RFA efficacy assessment Rate control simpler and often equally effective symptomatically Leong -Sit et al, Circ Arrhythm Electrophysiol. 2011;4: J. Liu et al. / Journal of Electrocardiology 43 (2010)

15 Rhythm Outcome post-ablation Upto 50% late recurrence in long standing persistent AF Lower recurrence in paroxysmal AF patients Necessary to maintain long-term rhythm surveillance All AF Weerasooriya et al, J Am Coll Cardiol 2011;57:160 6) Persistent AF; Median AF duration (pre):36 mnths Persistent AF; Median AF duration (pre):12 mnths Tilz RR et al, JCE 2010, 21;1085 Takahashi Y et al, Circ Arrhythm Electrophysiol 2010;3;

16 Strokes In Patients with AF Majority, but not all strokes in AF are cardioembolic Mostly due to lack of or subtherapeutic anticoagulation Stable suppression of AF should reduce but may not eliminate stroke risk Sherman DG et al for the AFFIRM investigators; Arch Intern Med. 2005;165:

17 Embolic Stroke Risk post AF ablation Advanced age (and higher CHADS2 score?) indicate risk Weigh embolic vs. bleeding risk New anticoagulants may reduce hemorrhagic stroke rates Role of appendage closure devices? Guiot et al, J Cardiovasc Electrophysiol, epub doi: /j x

18 Tailoring post Ablation Management Timing of re-do ablation: Prolonged rhythm symptoms, evolution surveillance before More intensive rhythm closing ASDs with a monitoring: device Asymptomatic AF AADs for poorly periods/episodes, longtolerated AF standing persistent AF, Long-standing prior embolic event persistent AF with LA Monitor LA contraction smoke, reduced LAA and LV remodelling: long velocities: strict standing persistent AF, anticoagulation heart failure