Dipen Shah Cardiology Service, University Hospitals, Geneva Switzerland

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1 Dipen Shah Cardiology Service, University Hospitals, Geneva Switzerland

2 Disclosures Research Grants: Biosense Webster, St. Jude, Bard, Endosense, Biotronik Speakers Honoraria: Biosense Webster, Endosense, Biotronik Consultancy: Endosense, Biosense Webster, Biotronik Stock Options: Endosense

3 1. Fuster V, et al. J Am Coll Cardiol. 2001;38: Go AS. et al. JAMA 2001;285: AF: The most frequent cardiac arrhythmia AF affects 1 in 25 individuals beyond 60 yrs of age and 1 in every 10 beyond 80 yrs million patients with AF in Europe and USA 1 The prevalence of AF is on the rise due to the progressive aging of the population 2

4 AF increases stroke risk with age % Significant increase with age p< % 9.9% 1.5% 2.8% Framingham Wolf et al. Stroke 1991;22:

5 AF is the principal arrhythmic cause for hospitalisation Hospital admissions in the US 1 AF AFL Cardiac Arrest Conduction Disease Junctional Premature Beats Sick Sinus Unspecified VF VT AF=Atrial fibrillation AFL=Atrial flutter VF=Ventricular fibrillation VT=Ventricular tachycardia Thousands of hospital days n=517,699 (representing 10% of cardiovascular admissions) 2 1. Bialy D et al. J Am Coll Cardiol 1992;19-41A 2. Waktare J. Difficult cardiology III V.3 p234

6 Consequences of AF Morbidity-mortality Risk of death multiplied by 2 1 Nearly 5 fold increased risk of a cerebrovascular accident 2 AF associated strokes are generally more severe than ischemic strokes of other causes 3 AF favours the development of heart failure and heart failure worsens AF which worsens overall prognosis 4 Quality of life Symptoms can result in considerable deterioration of quality of life 5 1 ESC 2012 guidelines 2 Wolf et al. Stroke 1991:22: Dulli DA et al. Neuroepidemiology. 2003;22(2): Wang TJ et al. Circulation 2003;107: Hamer ME et al. Am J Cardiol 1994;74:826 9.

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8 AF screening and management Diagnosis As early as possible Screening of asymptomatic individuals Early patient recognition of symptoms Adequate monitoring for ECG documentation Adequate first line therapy Anticoagulant therapy Rate and rhythm control therapy Underlying heart disease Choice of appropriate antiarrhythmic drugs

9 When should ablation be considered? As an alternative to anti-arrhythmic drugs: For patients with symptomatic, recurrent AF despite anti-arrhythmic drugs As first line treatment: For selected patients with symptomatic paroxysmal AF without associated structural heart disease The procedure should be performed by an experienced operator ESC 2012 recommendations

10 Complications Complication Type No. of Patients % of Patients Complication Type No. of Patients % of Patients 717 patients n= 961 procedures For all procedures (n=8745) Death Tamponade For LA procedures (n=7154) Stroke TIA Total Death 0 0 Tamponade/Peric ardial effusion 6/8 0.6/0.8 Stroke/TIA Hemorrhagic complications Total Complications Embolic 4* (0.4%) Tamponade 7 (0.7%) Gastroparesis 2 (0.2%) PV stenosis (asymptomatic) 4 (0.4%) Puncture site 8(0.8%) Hemothorax 1 (0.01%) n=9075 patients 100 centers 2002 n=1011 patients 10 centers 2005 n=717 patients HUG

11 Atrial Fibrillation ablation, ; HUG: n= (3%) 162 (22%) 539 (75%) < >74 Age range: 28 to 82 yrs

12 HUG AF Ablation Results, n=188, <65 yrs yrs >74 yrs n 154 (82%) 31 (16%) 3 (1.4%) Male 83% 71% 66% AF Parox/Persistent 73%/27% 68%/32% 66%/34% AF Duration 73±65 mnths (54) 84±72 mnths (51) 88 mnths LA size (echo) 4.2±0.7 cm 4.3±0.6 cm 5.1±0.8 cm LA volume (angio) 95±23 cc 98±23 cc 126±5 cc Procedure no./patient Complications PV stenosis 1.2% 3.2% 0 CVA+TIA 1.9% 0 0 Tamponade 1.2% 3.2% 0 Follow-up 40±20 mnths Stable SR w/o AAD 77% 61% 66% Stable SR with AAD 85% 71%

13 Catheter Ablation of AF: Recent Trials Weerasooriya et al, J Am Coll Cardiol 2011;57:160 6) Wilber et al, JAMA. 2010;303(4):

14 Rhythm outcome Mean follow up 8.7 ( ) yrs N of patients eligible (n=264) 11% 20% 23% 46% finished (n=121) loss of follow up or refuse to participate (n=61) awaiting for follow up with cardiologist (n=29) awaiting for questionnaire (n=53) % 35% SR (n=79) Failure (n=42) Total (n=121) Long term outcomes after atrial fibrillation ablation (LETITIA study), a preliminary report N. Tran, P. Gentil-Baron, e. Tessitore, C.-I. Park, H. Burri, H. Sunthorn, D. Shah Cardiology division, University Hospital of Geneva, Switzerland.

15 % Sinus Rhythm (n=79) Mean follow up 8.7 ( ) yrs 84% 89% % Parox AF (n=57) Non parox AF (n=22) Off OAC (n=66) Off AAD (n=70) Sinus rhythm (n=79) Long term outcomes after atrial fibrillation ablation (LETITIA study), a preliminary report N. Tran, P. Gentil-Baron, e. Tessitore, C.-I. Park, H. Burri, H. Sunthorn, D. Shah Cardiology division, University Hospital of Geneva, Switzerland.

16 Univariate analysis of predictors of long term recurrence during follow-up MR at 5 year (normal vs regurgitation) LA size at 5 year (normal vs abnormal) age (<=55 vs >55) no recurrence vs recurrence flecainide (no vs yes) amiodarone (no vs yes) BB (no vs yes) MR (normal vs regurgitation) LA size (normal vs abnormal) LVEF (normal vs abnormal) OR: 2.68 CI 95% [1.11; 6.47], P<0.033 OR: 4.93 CI 95% [1.89;12.86], P<0.001 Cardiopathy (no vs yes) CHADS-vasc (<2 vs >=2) OR: 3.13 CI 95% [1.43; 6.84], P<0.006 VD (no vs yes) Smoking (no vs yes) Cholesterol (normal vs abnormal) HTN (no vs yes) History of CVA (absent vs present) BMI (<30 versus >30) AF (paroxystic vs persistent) Sex (M/F) OR: 2.92 CI 95% [1.33; 6.44], P< OR

17 Safety of catheter ablation vs. AAD Treatment of Atrial Fibrillation with Antiarrhythmic Drugs (AAD) or Radiofrequency Ablation (RFA)1 Two separate systematic reviews (one on RFA and the other on AAD) compared clinical efficacy and safety of both therapies in the treatment of atrial fibrillation. (63 RFA and 34 AAD studies from 1990 to 2007 were included) Catheter ablation AAD 1. Calkins Circulation Arrhythmia 2009;2:349

18 HUG Re-Do Rates 2013: PAF & Pers. AF PAF Pers. AF Total n M/F 89/36 57/14 Age, y 59±12 63±10 LA vol. cc 85±23 114±28 Pers. AF duration, m - 10 months F-up, m 22±8 24±8 Re-Dos 15% 21% 17% AF/AT free (w/o AADs) PV recovery 100%; 2 PVs/pt. 89% 72% 82% 100%: 2.26 PVs/pt.

19 2012 focused update of the ESC Guidelines for the management of atrial fibrillation Catheter ablation is given a strong recommendation for patients with paroxysmal AF and little or no atrial remodeling provided it is conducted by experienced operators, and its use as a first-line therapy is also endorsed in similar circumstances. 19

20 MANTRA-PAF Nielsen et al, NEJM 2012; 367(17):

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22 ESC Guidelines for atrial fibrillation: Ablation 2010 Ablation for symptomatic AAD refractory PAF: Class IIa, level A Ablation without AAD trial for symptomatic PAF despite rate control: Class IIb, level B Post ablation bridging with LMWH/UFH to OAC: Class IIa, level C Ablation for symptomatic, drug refractory persistent AF, long standing persistent AF and AF with heart failure: Class IIa, IIb, & IIb respectively 2012 Ablation for symptomatic AAD refractory PAF: Class I, level A Ablation as first line treatment for symptomatic PAF: Class IIa, level B Ablation on continued OAC (VKAs): Class IIa, level B

23 Indications for (Catheter) Ablation of AF AF with refractory symptoms, AF with refractory heart rates; AF with heart failure Class I: Symptomatic, drug resistant PAF without structural heart disease IIa: Symptomatic drug resistant persistent AF To be considered: patient preference, structural heart disease, AF secondary to other arrhythmias Concomitant heart surgery* * per-operative AF ablation

24 First line Catheter Ablation of AF Symptomatic AF with high probability of ablation success (PAF) To be considered: patient preference, young age, absence of structural heart disease, sinus bradycardia, Brugada pattern/syndrome To be considered: AF with refractory heart rates; AF with heart failure Important: Operator and center experience PVI recommended

25 AF management strategies: A personal viewpoint Pharmacologic rate control or AVJ ablation Older patients with uncontrollable VR Inoperable calcific atria Contraindication to transseptal puncture Other indication for anticoagulation Already implanted PM Atrial defibrillator Atrial + ventricular ICD in patients with LV dysfunction / rare poorly tolerated PAF Atrial pacing Bradycardia support required Curative surgical treatment Concomitant open heart surgery Failed catheter approach? Curative catheter ablation Potentially widely applicable Better results with paroxysmal Afib