Atrial Fibrillation Ablation in Patients with Heart Failure Eleftherios M. Kallergis, MD, PhD, FESC Cardiology Department, Heraklion University Hospital
Since auricular fibrillation so often complicates very serious heart disease, its occurrence may precipitate heart failure or even death, unless successful therapy is quickly instituted Paul Dudley White 1886-1973
Atrial Fibrillation and Heart Failure : Epidemiology Wang T J et al. Circulation. 2003
Atrial Fibrillation and Heart Failure : Epidemiology Framingham Study: 22% HF pts developed AF over a mean follow-up of 4.2 years incidence rate 5.4% per year Wang T J et al. Circulation. 2003
Atrial Fibrillation and Heart Failure : Epidemiology AF prevalence relates with heart failure severity AF and HF have emerged as new cardiovascular epidemics Savelieva et al. Europace 2004
Atrial Fibrillation and Heart Failure : Epidemiology Mamas, Eur J Heart Fail 2009 and Aleong, The American Journal of Medicine 2014
Atrial Fibrillation and Heart Failure : Epidemiology The presence of AF is associated with increased mortality in both CHF pts with preserved and impaired LV systolic function Mamas, Eur J Heart Fail 2009 and Aleong, The American Journal of Medicine 2014
Atrial Fibrillation and Heart Failure : Epidemiology The presence of AF is associated with increased mortality in both CHF pts with preserved and impaired LV systolic function Mamas, Eur J Heart Fail 2009 and Aleong, The American Journal of Medicine 2014
Atrial Fibrillation and Heart Failure : A Vicious Pathophysiological Cycle
Atrial Fibrillation and Heart Failure : A Vicious Pathophysiological Cycle Sinus Rhythm Rhythm Control
Atrial Fibrillation and Heart Failure
Atrial Fibrillation and Heart Failure Rate or Rhyth Control In HF pts with AF
Rhythm or Rate Control? PIAF STAF AFFIRM RACE HOT CAFE Pts 252 200 4060 522 205 F-u (mo) 12 22 42 27 20 Age 60 65 70 68 61 AF Persistent Persistent Persistent/ Paroxysmal Persistent/ Recurrent after ECV Persistent Therapies Am-ECV Am-Prop-Fl-ECV Am-Sot-Prop- ECV Sot-Fl-Prop-Am- ECV Am-Sot-Prop Endpoint Symptoms Comp clinical events Death Comp clinical events Comp clinical events Results No differ No differ No differ No differ No differ None of these trials demonstrated the expected superiority of the rhythm control strategy
Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control 58% in the rhythm control group had at least one recurrence of AF during follow-up 40% in the rate control group was not in AF during the trial AF-CHF trial NEJM 2008
Rhythm or Rate Control? Effects of strategies diluted by:!suboptimal maintenance of SR by rhythm control strategies!not all patients in rate control strategy have persistent AF The beneficial effects of rhythm maintenance could have been counterbalanced by:!toxicity of antiarrhythmic drugs!significantly higher rate of use of beta blockers in rate control strategy
Sinus Rhythm in AFFIRM was Associated with Better Survival RR = 0.54 RR = 0.47 RR = 1.50 RR = 1.41 The AFFIRM Investigators, Circulation 2004
Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control CHF-STAT The spontaneous conversion of AF to sinus rhythm improved the survival rate in patients with HF Deedwania, Circulation 1998
Atrial Fibrillation and Heart Failure : Rhythm Control vs. Rate Control "In HF pts with AF, restoration of SR is associated with improved survival "This association was even more pronounced when the time of being in SR was included in the multivariate analysis and was independent of either treatment with dofetilide or placebo DIAMOND Substudy Circulation 2001
Antiarrhythmic Drugs and AF
Antiarrhythmic Drugs and AF If an effective method for maintaining SR with fewer adverse effects was available, it might be beneficial
Catheter Ablation of AF in Heart Failure Patients: Is it effective?
Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure 90 78 84 68 69 71 Sinus Rhythm 45 HF No HF Βορράς Στήλες 3-Δ 4 23 0 Total pts Off AADs "CA resulted in!long-term restoration of SR #without the use of AADs in most patients!significant improvement of exercise capacity, symptoms, and quality of life Haïssaguerre et al. NEJM 2004
Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure Improvement in LV Function and Dimensions after Ablation in Pts WIth CHF The LVEF improved significantly regardless of the presence or absence of concurrent heart disease or rate-controlled arrhythmia Haïssaguerre et al. NEJM 2004
Maintenance of NSR without AADs post AF ablation in patients with HF The maintenance of SR free of AADs post ablation ranged from 50% up to 87% Amin et al. World Journal of Cardiovascular Diseases 2013
CA for AF in Patients With Left Ventricular Systolic Dysfunction: Systematic Review and Meta-Analysis CA resulted in significant improvement of LV function Patients with CAD seem to benefit less than pts with other underlying diseases Dagres et al. J Cardiac Fail 2011
Catheter Ablation Versus Rate Control in the Management of AF in Heart Failure Efficacy Safety Clinical outcome
Catheter Ablation Versus Rate Control in the Management of Persistent AF in Heart Failure Single procedure success was 72%, and multi-procedural success was 92% The primary end point, peak oxygen consumption significantly increased in the ablation arm compared with rate control ARC-HF trial, J Am Coll Cardiol. 2013
Catheter Ablation Versus Rate Control in the Management of Persistent AF in Heart Failure Secondary end point measures of quality of life and BNP were improved significantly with CA Left atrial size was reduced by ablation, while EF showed only a nonsignificant increase ARC-HF trial, J Am Coll Cardiol. 2013
A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure "CA was able to restore SR in the majority of patients with peraf!improvement in left ventricular function #which was evident at 1 m and was sustained up to 1 y!reversal of left ventricular remodelling as evidenced by the reduction in ESV compared to the rate control group The CAMTAF Trial. Circ Arrhythm Electrophysiol. 2014
A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure The CAMTAF Trial. Circ Arrhythm Electrophysiol. 2014
A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure CA resulted in improved exercise capacity, BNP, NYHA class, heart failure symptoms and quality of life compared to a medical rate control strategy The CAMTAF Trial. Circ Arrhythm Electrophysiol. 2014
The CAMTAF Trial s Messages
The CAMTAF Trial s Messages Rhythm control using an ablation strategy is superior to the guideline recommended strategy of medical rate control in patients with HF!in terms of left ventricular function, exercise capacity and symptoms
The CAMTAF Trial s Messages Rhythm control using an ablation strategy is superior to the guideline recommended strategy of medical rate control in patients with HF!in terms of left ventricular function, exercise capacity and symptoms
The CAMTAF Trial s Messages Rhythm control using an ablation strategy is superior to the guideline recommended strategy of medical rate control in patients with HF!in terms of left ventricular function, exercise capacity and symptoms Patients who were codiagnosed with AF and HF had complete resolution of HF
The CAMTAF Trial s Messages Rhythm control using an ablation strategy is superior to the guideline recommended strategy of medical rate control in patients with HF!in terms of left ventricular function, exercise capacity and symptoms Patients who were codiagnosed with AF and HF had complete resolution of HF
The CAMTAF Trial s Messages Rhythm control using an ablation strategy is superior to the guideline recommended strategy of medical rate control in patients with HF!in terms of left ventricular function, exercise capacity and symptoms Patients who were codiagnosed with AF and HF had complete resolution of HF Tachycardia-mediated cardiomyopathy may be an over simplification!hf resolved after elimination of rate controlled AF, not tachycardia!patients were all adequately rate controlled
PABA-CHF: Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure 90 88 78 68 71 45 SR Δύση Βορράς 23 0 3 m 6 m 6 m off AADs Khan MN et al. N Engl J Med. 2008
PABA-CHF: Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure 90 88 78 68 71 45 SR Δύση Βορράς 23 0 3 m 6 m 6 m off AADs High incidence of progression of AF in AVN + BiV group More pts were receiving AADs in AVN + BiV group Khan MN et al. N Engl J Med. 2008
PABA-CHF: Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure Randomized trial of NYHA Class II or III CHF & EF <40% to PVI or AVN + BiV Distance (m) Score* 360 340 320 300 280 260 0 100 80 60 40 20 0 0 6-Minute walk PVI P < 0.001 AVN + BiV 3 6 Months PVI AVN + BiV P < 0.001 MLHF score* 0 Months 6 * Score = QoL Ejection fraction (%) 37 35 33 31 29 27 25 0 0 PVI Ejection fraction Months AVN + BiV PVI AVN + BiV 3 6 P < 0.001 Khan MN et al. N Engl J Med. 2008
PABA-CHF: Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure Randomized trial of NYHA Class II or III CHF & EF <40% to PVI or AVN + BiV terms of the ejection fraction, 6-minute walking distance, quality-of- 360 6-Minute walk PVI AVN + BiV 340 PVI 320 Ejection fraction P < 0.001 37 300 280 35 PVI AVN + BiV Patients 260 with nonparoxysmal AF derived more benefit from PVI in 33 0 P < 0.001 0 3 6 31 life score, and left atrial diameter Months 29 100 PVI AVN + BiV 27 80 P < 0.001 AVN + BiV MLHF score* 60 25 40 0 0 3 6 20 Months 0 0 Months 6 Distance (m) Score* * Score = QoL Ejection fraction (%) Khan MN et al. N Engl J Med. 2008
Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction 90 84 89 85 75 76 68 62 45 Normal EF<40 Diastolic 23 0 AAD free AF elimination AF control on or off AAD "AF ablation in pts with diastolic dysfunction is effective "with 1-year AF-free rates without and with AADs of 75% and 85% "and a 5-year atrial arrhythmia-free rate of 40% "Low procedural risk, LV function and QOL improvement Cha et al. Circ Arrhythm Electrophysiol. 2011
Catheter Ablation Versus Rate Control in the Management of AF in Heart Failure: Complications There are no differences in complication rates after CA, in patients with normal compared to impaired LV systolic function
Catheter Ablation Versus Rate Control in the Management of AF in Heart Failure: Complications There are no differences in complication rates after CA, in patients with normal compared to impaired LV systolic function
Key Questions Specific to Catheter Ablation of AF in Patients With HF
Key Questions Specific to Catheter Ablation of AF in Patients With HF Does catheter ablation improve mortality compared with a pharmacological rate control strategy?
Key Questions Specific to Catheter Ablation of AF in Patients With HF Does catheter ablation improve mortality compared with a pharmacological rate control strategy? Is the efficacy of catheter ablation for AF dependent on the etiology of HF!ischemic vs. nonischemic?
Key Questions Specific to Catheter Ablation of AF in Patients With HF Does catheter ablation improve mortality compared with a pharmacological rate control strategy? Is the efficacy of catheter ablation for AF dependent on the etiology of HF!ischemic vs. nonischemic? Are post-ablative improvements in functional capacity and quality of life preserved beyond 1 year?
Key Questions Specific to Catheter Ablation of AF in Patients With HF Does catheter ablation improve mortality compared with a pharmacological rate control strategy? Is the efficacy of catheter ablation for AF dependent on the etiology of HF!ischemic vs. nonischemic? Are post-ablative improvements in functional capacity and quality of life preserved beyond 1 year? Will the promising results achieved in smaller clinical trials be observed in larger clinical studies?
Ongoing Studies Comparing CA for AF Rhythm Control to Rate Control CASTLE-AF: Catheter Ablation Versus Standard Conventional Treatment in Patients with Left Ventricular Dysfunction and Atrial Fibrillation The composite of all-cause mortality or worsening of heart failure requiring unplanned hospitalization RAFT-AF: Rate Versus Catheter Ablation Rhythm Control in Patients With Heart Failure and High Burden Atrial Fibrillation Cardiovascular mortality
Rhythm Control Therapy May Become More Effective when it is Initiated Early
Rhythm Control Therapy May Become More Effective when it is Initiated Early The progressive nature of AF is partly caused by AF itself, but also reflects progression of underlying structural heart diseases There is evidence that the time course of AF stabilization in patients with structural heart disease is more rapid than in lone AF patients Early ablation could avoid AF progression
Since a reduced LVEF is an important predictor of mortality, the significant improvement in LV function after ablation could lead to enhanced survival
Conclusion
Conclusion AF and HF with impaired or preserved LV function coexist with increasing prevalence!increased mortality!deterioration of LV function, NYHA class, exercise tolerance, and quality of life
Conclusion AF and HF with impaired or preserved LV function coexist with increasing prevalence!increased mortality!deterioration of LV function, NYHA class, exercise tolerance, and quality of life
Conclusion
Conclusion Data from small size randomized studies showed feasibility and safety of AF ablation with improved outcome in patients with HF
Conclusion Data from small size randomized studies showed feasibility and safety of AF ablation with improved outcome in patients with HF
Conclusion Data from small size randomized studies showed feasibility and safety of AF ablation with improved outcome in patients with HF Ongoing studies will hopefully shed light on a multitude of endpoints,
A-Fib vs. EP Labs
A-Fib vs. EP Labs