In Whom and When Should Atrial Fibrillation Ablation be Considered?

Transcription

1 In Whom and When Should Atrial Fibrillation Ablation be Considered? Christian de Chillou, MD, PhD Department of Cardiology University Hospital Nancy, France ESC 2010 Stockholm, August

2 2 In Whom?

3 The 2006 ESC/AHA/ACC Guidelines Fuster V, et al. Eur Heart J 2006;27: Not so clear recommendations on rhythm control strategy, which was indicated in patients with disabling symptoms only

4 Rate control vs. rhythm control: still a debate? The AFFIRM Investigators N Engl J Med 2002;347: The AFFIRM Investigators Circulation 2004;109:

5 Efficacy of AAD to maintain SR is modest patients persistent AF 5 Van Gelder IC et al. Arch Int Med 1996;156: Carlsson J et al. J Am Coll Cardiol 2002;41:1690-6

6 ESC 2010 guidelines for the management of patients with AF Ablation > AAD Camm AJ, et al. escardio.org / doi: /euheartj/ehq278 6

7 Evidence-based Medicine Meta-analysis of randomized trials: PV isolation vs. AAD Paroxysmal AF = 92% 77% vs. 29% Odds ratio (ablation versus control) for freedom from 12 months 7 Wazni OM et al. JAMA 2005;293: Krittayaphong R, et al. J Med Assoc Thai 2003;86(Suppl 1):S8-S16 Jaïs P, et al. Circulation 2008;118: Pappone C, et al. J Am Coll Cardiol 2006;48: Stabile G, et al. Eur Heart J 2006;27: Piccini JP et al. Circ Arrhythm Electrophysiol 2009;2:626-34

8 Are there bad candidates for AF ablation? Congestive Heart Failure Elderly 58 pts with CHF Permanent AF =74% Long-term success w/o drugs =78% 8 Hsu LF et al. N Engl J Med 2004;351: University Hospital Bordeaux Zado E et al. J Cardiovasc Electrophysiol 2008;19:621-6 University Hospital Philadelphia

9 Are there bad candidates for AF ablation? Favorable outcomes after AF ablation: Hypertrophic Cardiomyopathy Bunch TJ et al. J Cardiovasc Electrophysiol 2008;19: Diabetes Mellitus Forleo GB et al. J Cardiovasc Electrophysiol 2009;20:22-8 Mitral Valve Prostheses Lang CC et al. J Am Coll Cardiol 2005;45: long-lasting AF in 36% long-lasting AF in 59% long-lasting AF in 48% There are some data, however, indicating that patients with long long-lasting persistent AF, massive left atrium enlargement & co-morbidities get less benefit from an AF 9 ablation procedure but there are no hopeless cases

10 10 When?

11 ESC 2010 guidelines for the management of patients with AF 11 Camm AJ, et al. escardio.org / doi: /euheartj/ehq278

12 12 LA-PV isolation in paroxysmal AF

13 Foci triggering AF: proof of a concept Diagram of the sites of 69 foci triggering atrial fibrillation in 45 patients. Haïssaguerre M et al. N Engl J Med 1998;339:

14 Natural History of AF Spontan. SR SR Parox. AF Pers. AF Pharmaco. Conv. Pers. AF Pharmaco. Conv. DC DC Pers. AF Pers. AF DC Pers. AF Perm. AF DC Perm. AF 14

15 Paroxysmal AF Permanent AF : 5.5% per year p < 0,05 Years 171 PAF patients (mean follow-up period: 14.1+/-8.1 years). Kato T et al. Circ J Jun;68(6):

16 Atrial remodeling leads to persistent AF 16 Allessie M et al. Cardiovasc Res 2002;54:230-46

17 Persistent AF ablation is more complex Brooks AG et al. Heart Rhythm 2010;7: PV antrum isolation LA ablation lines LA & RA ablation lines CFAE ablation PVI success rate = 2yrs Yamada T, et al. Europace 2007;9:770-4 Lim TW et al. Pace Clin Electrophysiol 2006;29:374-9 Kanagaratnam L et al. Pacing Clin Electrophysiol 2001;24: PVAI success rate = 1yr Cheema A, et al. Am J Cardiol 2007;99: Elayi CS, et al. Heart Rhythm 2008;5: Oral H, et al. J Am Coll Cardiol 2009;53:

18 and the success rate is lower as compared to paroxysmal AF ablation! Cappato R et al. Circ Arrhythm Electrophysiol 2010;3:

19 Atrial fibrillation begets atrial fibrillation! A curative therapy is probably more efficient at an early stage 19

20 Freedom from arrhythmia recurrence after persistent AF ablation 20 Matsuo S, Haïssaguerre M et al. J Am Coll Cardiol 2009;54:788-95

21 When should AF ablation be considered? As early as possible! Emerging indication: AF ablation as a first-line treatment 21

22 22 Conclusions

23 AF ablation : in whom and when? We should think about AF ablation just after the second patient we prescribe an AA medication because it will eventually fail in one of them Camm AJ, et al. escardio.org / doi: /euheartj/ehq278 23

24 Risk Benefit 24

25 Procedure-related complications of AF ablation 3 vs. 4, NS 25 Dagres N et al. Am Heart J 2009;158:15-20

26 Procedure-related complications of AF ablation Group 1 & 2 : Warfarin discontinued 3 days before the procedure and 1mg/kg enoxaparin was administered until 12 hours before procedure Group 3: Warfarin was not discontinued (INR between 2 and 3) before the procedure Heparin (bolus) during the procedure ACT > 350 seconds Di Biase L et al. Circulation 2010;121:

27 AF catheter ablation : contraindications Patients in whom catheter ablation may have catastrophic outcomes: - Left atrial thrombus - Severe carotid artery disease - Severe aortic stenosis - Non-revascularized left main or 3-vessel CAD - Severe pulmonary hypertension - HCM with severe left ventricular outflow tract obstruction - History of major lung resection 27 - Patients who cannot be anticoagulated both during and for at least 2 months after the ablation procedure

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