Invasive and Medical Treatments for Atrial Fibrillation. Thomas J Dresing, MD Section of Electrophysiology and Pacing Cleveland Clinic

Invasive and Medical Treatments for Thomas J Dresing, MD Section of Electrophysiology and Pacing Cleveland Clinic

Disclosures Fellow s advisory panel for St Jude Medical Speaking honoraria from: Boston Scientific Medtronic

Prevalence 0.4 1.0% of the population 2.2 million Americans Prevalence increases with age: 70% of patients with AF are between the ages of 65 and 85

Age Distribution

Prognosis Increased risk of stroke Increased risk of heart failure Increased risk of total mortality

Terminology Paroxysmal recurrent episodes (2 or more) which spontaneously terminate Persistent - recurrent episodes (2 or more) which does not spontaneously terminate Permanent (ICD-10 now uses term Chronic) AF which has either failed cardioversion or in which it is not ever attempted

Relative risk of stroke/mortality

Risk of stroke Various studies have estimated risk at least twice the rate in the non-af population May be as high as 15-20%/year in those over age 75 with multiple risk factors

Etiologies and Factors Predisposing Patients to AF - Part 1 Electrophysiological abnormalities Enhanced automaticity (focal AF) Conduction abnormality (reentry) Atrial pressure elevation Mitral or tricuspid valve disease Myocardial disease (primary or secondary, leading to systolic or diastolic dysfunction) A-V valvular abnormalities (causing ventricular hypertrophy) Systemic or pulmonary hypertension (pulmonary embolism) Intracardiac tumors or thrombi Atrial ischemia Coronary artery disease Inflammatory or infiltrative atrial disease Pericarditis Amyloidosis Myocarditis Age-induced atrial fibrotic changes

Etiologies and Factors Predisposing Patients to AF - Part 2 Drugs Alcohol Caffeine Endocrine disorders Hyperthyroidism Pheochromocytoma Changes in autonomic tone Increased parasympathetic activity Increased sympathetic activity Primary or metastatic disease in or adjacent to the atrial wall Postoperative Cardiac, thoracic, or esophageal Congenital heart disease Neurogenic Subarachnoid hemorrhage Nonhemorrhagic, major stroke Idiopathic (lone AF) Familial AF

Consequences Decreased cardiac output Decreased coronary perfusion Increased atrial volumes Consequences of tachycardia, incl. cardiomyopathy, valvular dysfunction Increased risk of thromboembolism

Treatment 3 principles Prevention of thromboembolic consequences Rate control Rhythm control

Prevention of thromboembolic complications CHADS2 Risk Criteria Score Prior stroke or TIA 2 Age 75 y 1 Hypertension 1 Diabetes mellitus 1 Heart failure 1

Prevention of thromboembolic complications Score Adjusted Stroke Rate (%/year) 0 1.9 (95% CI 1.2 to 3.0) 1 2.8 (2.0 to 3.8) 2 4.0 (3.1 to 5.1) 3 5.9 (4.6 to 7.3) 4 8.5 (6.3 to 11.1) 5 12.5 (8.2 to 17.5) 6 18.2 (10.5 to 27.4)

Prevention of thromboembolic complications CHADS2Vasc Risk Criteria Score Prior stroke or TIA 2 Age 75 2 Age 65-74 1 Hypertension 1 Diabetes mellitus 1 Heart failure 1 Female 1 Vascular Dz 1

Prevention of thromboembolic complications Score 0 0 1 1.3 2 2.2 3 3.2 4 4 5 6.7 6 9.8 7 9.6 8 12.5 9 15.2 Adjusted Stroke Rate (%/year)

Prevention of thromboembolic complications

Risk of ischemic stroke and intracranial hemorrhage for various intensity levels of anticoagulation

Why NOT use warfarin? Studies consistently confirm that for various reasons the time in therapeutic range (TTR) in patients on vitamin K antagonists (VKAs) is frequently <65% Warfarin has MANY drug and dietary interactions Time to therapeutic range is often delayed and is at best unpredictable, necessitating use of bridging therapy and overlap - associated with increased risk of bleeding while on dual therapy Genetic factors causing lack of response Need for testing and inconsistent follow-up/management

New medical therapies Anticoagulation Direct thrombin inhibitors dabigatran First to market First with an antidote Anti Xa agents Rivaroxaban Apixaban Edoxaban Reversal agent is close to approval These agents offer the benefit of not requiring monitoring of the INR with more predictable pharmacokinetics, fewer drug/diet interactions

NOACS versus warfarin: Efficacy and safety Ruff et al., The Lancet 2013

In whom would you NOT use a NOAC? A patient who doesn t want one Adverse reaction Cost Lack of trust in new medication Lack of antidote A patient with a mechanical valve A pregnant patient

Prevention of thromboembolic complications Minimum therapeutic anticoagulation period is 4 weeks before cardioversion and 4 weeks after cardioversion. 4 weeks before - Assumes possible thrombus formation and allows for dissolution 4 weeks after - Allows several weeks for atrial function to recover, as this may lag behind electrical conversion for several weeks

Prevention of thromboembolic complications Role of Transesophageal echocardiography (TEE) to assess for left atrial thrombus before elective cardioversion The ACUTE study Similar rates of thromboembolism (less than 1% during the 8 wk) for both: -TEE-guided strategy before elective cardioversion -Traditional strategy of anticoagulation for 4 wk before and 4 wk after elective cardioversion

Rate Control Generally goal is 60-80 bpm at rest and 90-130 bpm with exercise Commonly used agents Beta blockers Calcium channel blockers Digoxin Amiodarone

Rhythm Control Drugs and Typical Total Daily Doses Amiodarone 100 to 400 mg Dofetilide 250 to 1000 mcg Sotalol 160 to 320 mg Dronedarone 800 mg Flecainide 100 to 300 mg Propafenone 450 to 900 mg; SR 450-850 mg

Therapy algorithm

New medical therapies Azimilide Type 3 antiarrhythmic in family with amiodarone, sotalol and dofetilide Preliminarily, no better than available type 3 drugs Seems to have stalled in the approval process Combination therapies Type 1 and type 3 drug combined Dronedarone and ranolazine

Old therapies Cardioversion

Cardioversion

Catheter ablation Several Ablation Strategies Goal is same: to isolate or eliminate the triggers of atrial fibrillation Haissiaguerre paper in NEJM 1998: first to propose pulmonary vein ablation

Lesion set from the surgical Cox maze

Catheter ablation fluoroscopy appearance

Catheter ablation circular mapping catheter or lasso

Catheter ablation - lasso guided ablation

Catheter ablation irrigated tip

Catheter ablation strategy

Catheter ablation 3-D imaging

Catheter ablation 3-D image integration

Catheter ablation 3D imaging guidance

Intracardiac Ultrasound

Catheter ablation New ablation technologies

Surgical Treatment cut and sew

Surgical Treatment - Tools

Surgical Treatment

Surgical Treatment LA appendage excision

Watchman Device LA appendage occluder