علم االنسان ما لم يعلم

In the name of Allah, the Beneficiate, the Merciful ق ال هللا تعالي: 5 الدى علم بالق لم 4 علم االنسان ما لم يعلم سورة العلق It is He (Allah), Who has taught by the pen He has taught man which he did not know. Surah al-alaq

Atrial fibrillation and congestive heart failure are common cardiac disorders associated with substantial morbidity and mortality. They often coexist and negatively impact each other. Atrial fibrillation can lead to heart failure, and heart failure can lead to atrial fibrillation. AF is present in 10 to 50% of patients with heart failure.

an excessive ventricular rate a loss of atrial contraction an irregular ventricular filling time that is associated with atrial fibrillation may all have negative clinical consequences in patients with heart failure.

Most of available evidence suggests That heart failure patients with AF have a worse prognosis than those in whom a sinus rhythm is maintained and that the presence of AF is an Independent risk factor for death.

Morbidity Mortality and the Burden AF is independently associated with a two-fold increased risk of all-cause mortality in women and a 1.5-fold increase in men The direct costs of AF already amount to approximately 1% Of total healthcare spending in the UK, and between 6 26 Billion US dollars in the US for 2008.

Atrial Fibrillation is associated with High Mortality

. The earlier studies which have suggested that rhythm control affords no benefit over the rate control..has largely been invalidated (1,2,3). These early results were mostly in studies that compared rate control versus rhythm control pursued by using antiarrhythmic drugs (AADs). The neutral results were due in large part to the poor efficacy of AADs and their deleterious effects. 1. Roy D., Talajic M., Nattel S., et al. (2008) Rhythm control versus rate control for atrial fibrillation and heart failure.n Engl J Med 358:2667 2677. 2. Blackshear J.L., Safford R.E. (2003) AFFIRM and RACE trials: implications for the management of atrial fibrillation.card Electrophysiol Rev 7:366 369. 3. Nattel S. (2003) Rhythm versus rate control for atrial fibrillation management: what recent randomized clinical trials allow us to AFFIRM. CMAJ 168:572 573.

Strategy for Rhythm control Craig T. January et al. JACC 2014;64:2246-2280 American Heart Association, Inc., the American College of Cardiology Foundation, and the Heart Rhythm Society

RESTORING THE SINUS RHYTHM Let us review some of the recent studies that have shown catheter ablation of AF, if results in durable sinus rhythm in CHF, is superior to both Rate Control and Rhythm Control using Anti Arrhythmic medications in patients with CHF.

Circulation March 30 th 2016 AATAC Multicenter Randomized Trial Ablation Versus Amiodarone for the Treatment of Persistent Atrial Fibrillation in Patients With congestive heart f ailure and an implanted device Results from the AATAC Multicenter Randomized Trial. Circulation. 2016;133:1637-1644. DOI: 10.1161/CIRCULATIONAHA.115.019406

Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD (AATAC) 1. A randomized study assessing whether catheter ablation is superior to AMIO for the treatment of AF. 2. Patients 18 years of age. 3. Persistent AF, with dual-chamber ICD or CRT-D 4. CHF NYHA Class II to III. 5. LV EF 40% within the past 6 months were enrolled at multiple centers. ICD = implantable cardioverter defibrillator, CRT-D=r cardiac resynchronization, EF=Ejection fraction

PRIMARY END POINT: Freedom from AF, atrial flutter, or atrial tachycardia of more then 30 seconds duration off anti arrhythmic medications. SECONDARY END POINTS: All-cause mortality. Unplanned hospitalizations during post ablation follow up. (for atrial fibrillation or heart failure decompensation) Change in LVEF. 6-minute walk distance (6MWD). QoL measured by Minnesota Living with Heart Failure Questionnaire (MLHFQ).

THE PROTOCOL PVI and Posterior wall Isolation CTI block and SVC isolation VS Loading dose was given in divided doses: 400 mg given orally twice a day for 2 weeks followed by 400 mg each day for the next 2 weeks. Once the loading phase was completed, the maintenance dose of AMIO was 200 mg a day. PVI=pulmonary vein isolation, CTI=Cavotricuspid isthmus, SVC=superior venacava

Kaplan Meier curve comparing AF-free survival between patients undergoing catheter ablation (group 1) and those receiving amiodarone therapy (group 2). At end of the study, 71 (70%; 95% CI, 60% 78%) patients in group 1 were recurrence free in comparison with 34 (34%; 95% CI, 25% 44%) in group 2 (logrank P<0.001). AF indicates atrial fibrillation; AT, atrial tachycardia; and CI, confidence interval.

CONCLUSION This multicenter randomized study shows that catheter ablation of AF is superior to AMIO in achieving freedom from Atrial Fibrillation and reducing unplanned hospitalization and mortality in patients with HF and persistent AF. Di Biase et al Amiodarone and AF Ablation in Heart Failure 1641

The CAMTAF trial also showed a significant improvement of LV EF after 6 months of follow-up with AF ablation in comparison with pharmacological rate control. +8.1 [95% CI, 3.0 13.1] VS 3 [95% CI, 7.7 to 0.5]; P=<0.001. Similarly, the ARC-HF trial reported a trend toward a higher LVEF improvement with AF ablation. after 12 months of follow-up.14 (mean difference, +5.6% (95% CI, 0.1 to +11.3; P=0.055)

Catheter Ablation for Atrial Fibrillation in Heart Failure Patients. A Meta-Analysis of Randomized, Controlled Trials 1. Trials including only patients with persistent AF were analyzed, excluding a trial that included patients with both persistent and paroxysmal AF. 2. Trials that used only pharmacologic rate control were analyzed, excluding a study that used AV node ablation with biventricular pacing as a rate control strategy. 3. One trial assessed LVEF by means of 2 methods, with different results. Both results were used in a sensitivity analysis. 4. The LVEF for inclusion in 3 trials was <40% and in 1 trial was <50%. The trial with LVEF criterion of <50% was excluded as a sensitivity analysis. 5. All trials had >80% of patients free of AF after ablation, except 1 trial, which had >50% of patients free of AF. This trial was excluded as a sensitivity analysis J A C C : C L I N I C A L E L E C T R O P H Y S I OL OG Y V O L. 1, NO. 3, 2 0 1 5, Al Halabi et al. J U N E 2 0 1 5 : 2 0 0 9

Primary and Secondary End points Primary clinical endpoints: 1. Change in LVEF after 6 months. Secondary endpoints: 1. Minnesota Living with Heart Failure questionnaire scores, (MLWHF) for Qol. 2. 6-min walk test distance. 3. Peak oxygen consumption.

CHANGES IN FUNCTIONAL OUTCOME LV EF 6 MWT MLWHF VO2 C LV EF= Left ventricular Ejection Fraction change, MLWHF= change in Minnesotta Living with Heart Failure Score 6 MWT= change in six minutes walk test, VO2 C = Change in Peak oxygen consumption

CONCLUSIONS AF catheter ablation strategy in patients with AF and HF results in 1. Improved LV function. 2. Functional capacity. 3. HF symptoms. 4. Quality of life compared with a rate-control strategy. Patients with HF may be at higher risk of complications with interventional approaches for both rhythm and rate-control strategies. However, this analyses suggest that, before accepting a rate-control strategy in HF patients with persistent or drug-refractory AF, an individualized approach should be pursued, including consideration to performing AF catheter ablation in appropriately selected patients. J A C C : C L I N I C A L E L E C T R O P H Y S I OL OG Y V O L. 1, NO. 3, 2 0 1 5, Al Halabi et al. J U N E 2 0 1 5 : 2 0 0 9

October 2017 The CAMERA-MRI Study Catheter Ablation vs Medical Rate Control in AF and Systolic Dysfunction Prabhu et al CAMERA-MRI study. J Am Coll Cardiol 70:1949 1961

The effect of AF ablation on top of rate control in symptomatic patients with Dilated Cardiomyopathy was studied. All patients underwent Cardiac Magnetic Resonance Imaging (MRI) to assess for late gadolinium enhancement, (LGE)a marker of scarring. CAMERA-MRI study. J Am Coll Cardiol 70:1949 1961.

Sandeep Prabhu et al. JACC 2017;70:1949-1961 MRI-Detected Midwall Ventricular Fibrosis in Idiopathic Cardiomyopathy An example of midwall fibrosis as detected by the presence of late gadolinium enhancement (LGE) on CMR. Panel A shows a short-axis view demonstrating midwall fibrosis highlighted in white along the inter-ventricular septum (arrows). Panel B shows a patient with no detectable LGE. 2017 American College of Cardiology Foundation

2017 American College of Cardiology Foundation Sandeep Prabhu et al. JACC 2017;70:1949-1961

Sandeep Prabhu et al. JACC 2017;70:1949-1961 2017 American College of Cardiology Foundation

EF Improvement was particularly marked in patients with late gadolinium enhancement-negative MRI (no scar) The catheter ablation resulted in the reduction of LV and LA dimension, BNP levels, and NYHA functional class. Thus it can also be concluded, that in some patients, Atrial Fibrillation, with no LV scar, and even when the ventricular rate is well controlled could result in Dilated cardiomyopathy. Prabhu et al CAMERA-MRI study. J Am Coll Cardiol 70:1949 1961

THIS STUDY IS NOT PUBLISHED YET AND FOLLOWING SLIDES ARE THE COURTESY OF BIOTRONIC COMPANY. STUDY WAS RUN BY PROF. MARROUCHI AND PRESENTED IN EUROPEAN SOCIETY OF CARDIOLOGY 2017 CONGRESS ON 27 th. August in Late breaking clinical Trial Session.

STUDY DESIGN aaaaa

aaa

MAIN RESULT OF THE TRIAL

CASTLE- AF CONCLUSION The CASTLE-AF trial results indicate that the Catheter ablation of the atrial fibrillation in heart failure Patients Improves outcome by reducing mortality and morbidity Reduce the AF burden by 50 % Catheter Ablation of AF might be suggested as a first line therapy Cather Ablation should be performed earlier then later.

Improves outcome by reducing mortality Improve the NYHA functional Class Reduce the AF burden. Improve the Exercise Capacity Improve the quality of life Catheter Ablation of AF might be suggested as a first line therapy Cather Ablation should be performed earlier then later.

THANK YOU FOR YOUR ATTENTION