Interesting EP Cases Catheter ablation to treat congestive heart failure (CHF)

Transcription

1 Interesting EP Cases Catheter ablation to treat congestive heart failure (CHF) Yiming WU, MD, PhD. Alaska heart and vascular institute

2 19 yo man transferred for out side hospital cardiac arrest d/t ventricular fibrillation s/p cardioversion x3. + for meth, EF 45% and recovered to 60% in 3 days.

3 Prevalence of Early Repolarization in patients with idiopathic VF and controls Sudden Cardiac Arrest Associated with Early Repolarization N Engl J Med 2008; 358: % 50% 40% 30% 20% 10% 0% Idiopathic VF Controls P = Actuarial Curves for Case Subjects with VT, According to the Presence or Absence of Early Repolarization(Mean follow up 61 +/- 50 months); risk for recurrent VF.

4 Case reports, case control studies, and population studies established a link between the presence of ER and an increased risk for arrhythmic death / idiopathic ventricular fibrillation (VF) Estimated risk of developing idiopathic VF in an individual younger than 45 years is 3 in 100,000; The risk increased to 10 in 100,000 when J waves present. Association of ER with arrhythmic risk is typically at rest or during sleep and not during physical activity when J-point elevation is typically markedly reduced or eliminated. Among survivors of SCD due to idiopathic VF, the reported rate of recurrent VF ranges between % at 2-4 years; 41% at follow up of 5 years. Because ER syndrome patients have no structural heart disease, they have an excellent prognosis for long-term survival if VF is treated

5 60 yo woman transferred for, severe MR, atrial flutter with RVR, v fib post cardioversion.

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7 Synchronized cardioversion: Timing of shock to avoid peak of T wave. Prevents VF caused by delivering shock during venerable period.

8 Location, location and location. Timing, timing and timing. The first ECG record of VF after a blow to the chest of a hare using a hammer. Maron BJ and Estes III NAM, NEJM 362:917, 2010.

9 Ms. JLF, 64 yo, female, referred for possible ICD implantation on 4/1/2014. Paroxysmal atrial fibrillation since Chronic atrial fibrillation at least since 11/2013. Failed cardioversion and on rate control. All EKGs show that the ventricular rate between bpm indicating well rate controlled. On optimal CHF medication. LVEF: 55-60% (2011), 45% (11/2013), 35% (2/2014). Coronary angiogram (11/2013): non-obstructive CAD.

10 Diagnosis: non-ischemic cardiomyopathy (NICM). Next: 1. Can exclude the NICM is due to atrial fibrillation. 2. ICD implantation for primary prevention. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators.

11 How to test the hypothesis: atrial fibrillation causes NICM? Rhythm control: antiarrhythmic drug or ablation. Amiodarone was loaded and cardioverted into sinus rhythm. LVEF: 45% (5/2014), 51-55% (3/2015), 56-60% (7/2015), 56-60% (10/2016)

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14 Worried about side effects of Amioraone. Underwent catheter ablation 7/9/ /28/2017 evaluated in clinic, still in sinus rhythm

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16 Mechanisms for AF to induce HF Irregular rhythm decreases cardiac output. Persistent tachycardia may lead to tachycardia mediated cardiomyopathy. Loss of atrial systole required for optimal ventricular filling. Activation of neuro-humoral vasoconstrictors.

17 58 pts with AF+CHF, LVEF 45%, F/U a mean (±SD) of 12±7 months post ablation. 78% still in sinus rhythm Hsu L, et al, Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure. N Engl J Med 2004; 351:

18 Atrial fibrillation and CHF (AF-CHF trial) rate control vs. rhythm control A multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes Roy D, eat al. Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure. N Engl J Med 2008; 358:

19 Roy D, eat al. Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure. N Engl J Med 2008; 358:

20 Benefits: rate control = rhythm control. Amiodarone harms the patients and reduces the benefits of rhythm control. Famous CAST Echt DS, et al. Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781-8

21 203 CHF + Persistent AF pts with device (ICD), LVEF 0.40, NYHA II-III. AATAC-AF: Secondary Endpoints Cardiovascular Hospitalization All-Cause Mortality Ablation Amiodarone P Value 32 (31%) 58 (57%) < (8%) 18 (18%) Biase L, et al. 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. Circulation. 2016;133:

22 Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study This multicenter, randomized patients with persistent AF and idiopathic cardiomyopathy (LVEF 45%). Pts underwent CMR to assess LVEF and late gadolinium enhancement (ventricular fibrosis) then randomization to either CA or ongoing MRC. The primary endpoint was change in LVEF on repeat CMR at 6 months. (33 pts in each group)

23 CONCLUSIONS: AF is an underappreciated reversible cause of LV systolic dysfunction (LVSD) in this population despite adequate rate control. The restoration of sinus rhythm with catheter ablation (CA) results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on cardiac MRI. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD.

24 Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation. (CASTLE-AF trial) 397 pts with symptomatic paroxysmal or persistent AFib and a left ventricular ejection fraction (LVEF) of 35 %, with ICD or CRTD, for radiofrequency catheter ablation or conventional drug treatment. In SR at 60 m: Ablation: 63.1% MRC: 21.7%

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27 Ablation MRC Death 13.4% 25.0% CHF admission 20.7% 35.9% CV death 11.2% 22.3% LVEF change 8.0% 0.2%

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29 By the year 2030, there will be 12 million Americans with AF, and over 8 million with HF individuals ( ) with new AF, (75±12 yo, 48% F) more than one third (37%) had HF individuals with new HF (79±11 yo, 53% F), more than half (57%) had AF. Prevalent AF was more strongly associated with incident HFpEF vs HFrEF. Prevalent HF was associated with incident AF. AF precedes and follows HF with both preserved and reduced ejection fraction. The presence of both AF and HF portended greater mortality risk. Santhanakrishnan, J. et al. Circulation. 2016; 133:

30 Atrial fibrillation can cause CHF even with well ventricular rate controlled. Because irregularity can reduce the myocardial contractility, like PVCs and PACs. Catheter ablation is superior to medication.

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32 78 yo male from Valdez with CAD, MI s/p PCI. Echo (TTE) in 9/2017: LVEF 40-45%, No MR, moderate AS (AVA 1.0 cm2, normal cm2). EKG: 11/2016: SR. 9/2017: A fib Worsening CHF on optimal medical treatment. TEE (2/9/2018): LVEF 15-20%, moderate to severe MR, moderate to severe AS. Had atrial fibrillation ablation yesterday.

33 Dr.Wu~ I feel like my life has been handed back to me as I've been out shooting some photography and walking the bike trails. And I've been arrhythmia free for 20 days now!! I've had a PVC or two but they are random. I thank you with all of my happy heart! I've included a couple of my photos :)

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35 43 yo, female, fatigue, otherwise asymptomatic. LVEF 35% Sinus rhythm and PVCs?

36 RSPV CS His Bondle

37 RL PA

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39 Post ablation Before ablation

40 Repeated echo 5 wks later: LVEF 62%. Lisinopril and metoprolol were discontinued. Echo 5 months later: LVEF 60%.

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42 75 yo female, tired and dizzy, pulse rate ~ 40 bpm. PCP sent her for evaluation of pacemaker implantation

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44 Dog model of bigeminal PVC Jose F. Huizar et al. Circ Arrhythm Electrophysiol. 2011;4:

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46 Activation and pacing mapping indicated RVOT PVC. The PVC was successfully ablated.

47 Why not anti-arrhythmic medication Famous CAST Echt DS, et al. Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781-8

48 28 yo, F, palpitation for 7 years. PVCs refractory to beta blockers and mexilletine. Echo: LVEF 38%. 48 Holter reveals 32.4% PVCs

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50 Does she need a PVC ablation: symptom? CHF? Cosmetic?

51 PVC ablation, RVOT PVC

52 Echo (5 months later): EF 67%. 48 holter (5 months later): 1% PVCs.

53 6-month survival of patients post MI by premature ventricular contractions (PVCs) per hour J Lifestyle Med ; 3(1):

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55 Ventricular Ectopy as a Predictor of Heart Failure and Death. Objectives The goal of this study was to determine whether PVC frequency ascertained using a 24-h Holter monitor is a predictor of LVEF decline, incident CHF, and death in a population-based cohort. Quartiles 1 through 4 represent PVC burdens of 0% to 0.002%, 0.002% to 0.011%, 0.011% to 0.123%, and 0.123% to 17.7%, respectively J Am Coll Cardiol ; 66:

56 Conclusions In a population-based sample, a higher frequency of PVCs was associated with LVEF decline, increased incident CHF, and increased mortality. The population-level risk for incident CHF attributed to PVCs was 8.1% (95% CI: 1.2 to14.9%). Given the capacity to prevent PVCs through medical or ablation therapy, PVCs may represent a modifiable risk factor for CHF and death. J Am Coll Cardiol ; 66:

57 Dogs, couple interval 240 ms, RVA PVCs Heart Rhythm. 2016; 13:

58 PVC burden of >24% had a sensitivity and specificity of 79% and 78%,

59 J Am Coll Cardiol 2013;62: )

60 Risk factors for PVCs induced cardiomyopathy (CMP) 1) PVC burden: Baman et al.: 24%. Munoz F, et al. (J Cardiovasc Electrophysiol. 2011;22:791 8): PVCs originating from the RV 10%, PVCs originating from the LV 20%. Can H, et al, ( J. Cardiovasc. Electrophysiol. 2011;22:663 8): 16%. Ban Ji-Eun et al, (Europace. 2013;15:735 41): 26%. Many others: 10% So far, there are no clear-cut points that mark the frequency at which CMP is unavoidable. 2) PVC origin, morphology and duration: RV origin. Wider QRS. Shorter couple interval 3) Underlying heart diseases.

61 4 centers, 80 pts, 27 pts with SHD. Successful PVC ablation in 53 pts. Gray bar = no SHD, black bar= SHD. Independently of the presence of SHD, improvement in heart failure parameters was related to baseline PVC burden and persistence of ablation success. J Am Coll Cardiol 2013;62: )

62 Catheter ablation Conventional treatment (ACEI, BB) Latchamsetty RY, Morady Miki, Kim Fred, et al. Multicenter outcomes for catheter ablation of idiopathic premature ventricular complexes. JACC: Clin Electrophysiol. 2015;1: Bogun F, Crawford T, Reich S, et al. Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: Comparison with a control group without intervention. Heart Rhythm. 2007;4:863 7.

63 If cardiomyopathy causes PVCs, then successful ablation of PVC may slightly increase or does not change LVEF. Or the LVEF even continuously reduces but hopefully slower.

64 Early Elimination of Premature Ventricular Contractions in Heart Failure (EVAC-HF) Inclusion Criteria: Patients with reduced ejection fraction (EF 45%) demonstrated by transthoracic echocardiogram and deemed to be non-ischemic by nuclear stress test or cardiac catheterization. Patients with >20% PVCs on 24 hour holter-recording Patient is 18 years of age or older Optimized medical therapy on stable therapy for minimum 3 months with no changes in beta-blocker, ACE-I/ARB, digoxin doses (varying diuretic doses permitted).

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66 30 yo man, in ER, normal heart per echo avr avl Outflow tract VT: Structurally normal Normal LVEF RVOT or LVOT EKG: LBBB, + QRS in II/III/aVF, -QRS in avr/avl Not life-threatening CAMP dependent VT Sensitive to CCB/BB NO ICD Ablation has good outcome II/III/aVF

67 Except rapid pacing induced CM, all the other arrhythmias on the list can be treated by catheter ablation. J Am Coll Cardiol. 2015; 66(15):

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