Long-Term ECG Monitoring Using an ILR. Evgeny Pokushalov, MD, PhD

Transcription

1 Long-Term ECG Monitoring Using an ILR Evgeny Pokushalov, MD, PhD

2 Long- Term ECG Monitoring Using an ILR Evgeny Pokushalov, MD, PhD, FESC State Research Ins;tute of Circula;on Pathology, Novosibirsk, Russia

3 Guidelines for AF management No data exist on the implementation of ILR in the clinical routine of AF monitoring hour Holter monitoring is an acceptable minimal monitoring strategy for patients enrolled in a clinical trial... Leadless ILR provide continuous AF monitoring over a 2 year period with automatic AF detection based on RR interval analysis...

4 After ablation the percentage of patients with only asymptomatic AF recurrences increased to 37% Asymptomatic episodes may occur and significantly increase after catheter ablation

5 Of the 163 symptomatic events, 52% were actual AF, 42% were sinus rhythm and 6% were other rhythms The lack of correlation between symptoms and rhythm underscores the importance of continuous home monitoring for accurately quantifying preoperative atrial fibrillation burden and for postoperative follow-up

6 The success rate in terms of freedom from AF was 70% on a symptom-onlybased followup; using serial 7-day Holter it decreased to 50% and on transtelephonic monitoring to 45%, respectively Transtelephonic ECG and serial 7-day Holter were equally effective to objectively determine long-term success and to detect asymptomatic patients

7 Today different ablation strategies are used for catheter ablation of AF. However, as studies evaluating and comparing these strategies have used different follow-up methods and definition of success, the comparison of these methods are very difficult. Arya A. et all. Pace 2007

8 In this ICM validation study, the dedicated AF detection algorithm reliably detected the presence or absence of AF and the AF burden was accurately quantified. The ICM is a promising new diagnostic and monitoring tool for the clinician to treat AF patients independently of symptoms.

9 PVI. Real efficacy. Continuous ECG Monitoring

10 PVI. Responders. after 1 procedure after 1 or more procedures 80 Paroxysmal AF 90 Paroxysmal AF Persistent AF Persistent AF Pokushalov E.. et al. JCE 2011; 22(4);

11 PVI. Nonresponders. Paroxysmal AF Persistent AF 5 (7%) patients had AT stored by the ILR Patients with AF>0.5% accounted for 18 (25.4%) The overall group with recurrences was 23 (32.4%) patients 3 patients (11.5%) were completely asymptomatic After the additional procedures 14 (19.7%) patients were nonresponders, i.e. AF >0.5% 6 (10.3%) patients had AT stored by the ILR Patients with AF>0.5% accounted for 24 (41.4%) The overall group with recurrences was 30 (51.7%) patients 4 patients (13.3%) were completely asymptomatic After the additional procedures 21 (36.2%) patients were nonresponders, i.e. AF >0.5% Pokushalov E.. et al. JCE 2011; 22(4);

12 SB ST AF PAC 1292 (68%) episodes were not confirmed as AF episodes on analysis of the corresponding ECG Normal SR Pokushalov E.. et al. JCE 2011; 22(4);

13 Open Heart Surgery. Real efficacy

14 Ngaage DL. et all. Does preoperative atrial fibrillation influence early and late outcomes of coronary artery bypass grafting? J Thorac Cardiovasc Surg 2007;133:182-9 Quarder M.A. et all. Does Preoperative Atrial Fibrillation Reduce Survival After Coronary Artery Bypass Grafting? Ann Thorac Surg 2004;77:

15 State Research Institute of Technique Epicardial right PVI Epicardial right PVI ILR implantation Pokushalov E. et all. EJCTS 2011

16 Responders % (27.8%) patients had atrial arrhythmia recurrences at 12 months of follow-up 17 (23.6%) patients had AF only and 5 (6.9%) patients had atrial tachycardias 6 (30%) patients were completely asymptomatic Pokushalov E. et all. EJCTS 2011

17 Does AF burden predict the response to ablation?

18 AF burden % Pokushalov E. et all. Heart Rhythm 2012

19 AF burden - 4.5% The corresponding value in AF burden is 4.5% Sensitivity - 90% Specificity - 85% Pokushalov E. et all. Heart Rhythm 2012

20 Strategy for managing patients with AF recurrences after the first ablation

21 When the first abla;on fails and the pa;ent has AF recurrences, the physician must choose: rate control, perform a second abla;on procedure, implement AAD therapy, undertake a second abla;on plus AAD There are no clinical markers that can reliably indicate the most appropriate approach 20

22 Avoiding reablation within the blanking period of 3 months 21

23 Recurrence of AF in the period shortly following PVI is a common finding, but one that does not always signify ultimate outcome (Oral, 2002) The significance of such early recurrences (ER) are controversial (Jais, 2008). These data have suggested a range of possibilities for the blanking period from 1 month to 3 months Numerous data suggest that anatomic and electrical atrial remodeling may play an important role in favoring postablation arrhythmias. Many investigators consider that ER should be treated by antiarrhythmic drugs until atrial remodeling has taken place and any inflammation from the procedure has settled (Natale,2008) Many investigators confirm that EAT are very frequent and demonstrate that such arrhythmias have an unfavorable prognostic significance in that they are strong predictors of LAT (Natale,2008)

24 More then 30% of patients with paroxsymal AF will require at least two procedures to treat arrhythmia recurrences that occur outside this blanking period (Jais,2006) An early second procedure (within the first month after the first AF ablation) reduces recurrent arrhythmia; however, the total number of needed ablation was higher in patients with early reablation (Haissaguerre,2008)

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26 Freedom from recurrent arrhythmias Freedom from further ablation

27 Longterm freedom from a third ablation in patients with early or late second ablation The total number of ablation procedures needed in patients with early second procedure was significantly higher compared with patients without early second ablation (2.5 ± 0.7 vs 2.2 ± 0.6, P = 0.02)

28 Pokushalov E. et all. Circulation

29 Examples of onset mechanisms: A: Sinus rhythm before the onset of AF B: Atrial tachycardia triggering AF C: Premature atrial contractions triggering AF Pokushalov E. et all. Circulation

30 AF/AT freedom aqer 3 months Pokushalov E. et all. Circulation

31 AF/AT freedom aqer 3 months Pokushalov E. et all. Circulation

32 VS. No ER typing ER typing the total number of procedures over the entire follow-up was greater in those patients with early reablation (2.5 ± 0.7 vs 2.2 ± 0.6, P = 0.02). The total number of ablation procedures in Group 4 and Group 3 was similar: 1.82 ± 0.5 vs 1.79 ± 0.7, P = 0.28

33 Thank you! 32