Atrial fibrillation: Who should be referred for ablation therapy for atrial fibrillation?. September 12 th, PDF Free Download

Atrial fibrillation: Who should be referred for ablation therapy for atrial fibrillation?. September 12 th, 2015 MMMMMMM MMMMMMM MMMMMMM Sohail Hassan MD FACC, FHRS Director, Cardiac Electrophysiology St John Hospital, Detroit MI Assistant Professor of Medicine Wayne State University

Believe in better Atrial ﬁbrilla/on: WHO HAS IT? G Bush Senior: VP Joe Biden Lary Bird Howie Mandel Believe in better VP Dick Chene Elton John Barry Manilow Hakim Elijuan

GOALS OF THERAPY Prevent stroke Anticoagulation Relieve symptoms Rate control Maintain sinus rhythm

Five things to remember for a pt with atrial fibrillation Figure out why pt in afib. Careful BP assessment Physical exam Echocardiogram LV function and LA size. TSH, Sleep study. Figure out extent of symptoms/disability SAF Class (0-4) Calculate stroke risk CHADS2 VASC score. Start with rate control. Consider referral if symptomatic. If asymptomatic STILL AN EVALUATION BY A CARDIOLOGIST AND AN ELECTROPHYSIOLOGIST IS INDICATED.

Young Patient with Atrial fibrillation 40 yr old male Seen in ED with new onset palpitations Started 2 hrs ago. One episode a month with dizziness lasting 2 hours. BP is 150/80 Echo LA dimension is 5.0 cm. ef wnl, no MR Otherwise healthy but nervous ECG: atrial fib 160 Rx d with beta blocker: HR 85. cardiologist/ EPS starts pt on Propafenone 150mg tid>>titrated up to 225tid Feels much better for one year and now symptoms are back.. IS HE A GOOD CANDIDATE FOR ABLATION THERAPY

AF Catheter Abla/on to Maintain Sinus Rhythm Believe in bet ter Recommendations AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired. Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy. COR LOE I A I C IIa A IIa B

CASE NO 2. 65 yr. old asymptomatic male with atrial fibrillation, holter shows 24 hours of constant atrial fibrillation. Diagnosed when pt was referred for screening colonoscopy. Only comorbidity is HTN and sleep apnea. 1. SHOULD we be worried about atrial fibrillation? 2. Is this pt at risk of stroke? YES 3. Should he Undergo ablation therapy?

SHOULD we be worried about atrial fibrillation?

AF Catheter Abla/on to Maintain Sinus Rhythm (cont d) Recommendations AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired. AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and after the procedure. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. COR LOE IIb IIb III: Harm III: Harm B C C C

Does atrial fibrillation ablation decrease the risk of stroke? Studies are mainly focused on pt with low to moderate risk of stroke when anticoagulation were stopped after ablation. The largest study was performed by Reynolds et al.7 Over a 3-year follow-up, they reported an annual stroke risk of 1.6% for patients after AF ablation and 2.7% on antiarrhythmic drugs. Reynolds MR, Gunnarsson CL, Hunter TD, et al. Health outcomes with catheter ablaoon or anoarrhythmic drug therapy in atrial fibrillaoon: results of a propensity- matched analysis. Circ Cardiovasc Qual Outcomes. 2012;5(2):171-181.

Believe in better Believe in better

CASE 3 76 YR OLD GENTLEMAN WITH PERSISTENT A FIB, PLAYS TENNIS COMPLAINS OF FATIGUE. TWO ENDOVASCULAR ABLATIONS FOR ATRIAL FIBRILLATION SEVERELY SYMPOMATIC. HTN EF IS 55%. LA SIZE IS 5.0 CM. IS THERE ANOTHER OPTION FOR THIS PT. Reynolds MR, Gunnarsson CL, Hunter TD, et al. Health outcomes with catheter ablaoon or anoarrhythmic drug therapy in atrial fibrillaoon: results of a propensity- matched analysis. Circ Cardiovasc Qual Outcomes. 2012;5(2):171-181.

Surgical Maze Procedures Recommendations An AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications. A stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches. COR LOE IIa C IIb B

Believe in better St John Arrhythmia Management team: Dr D. Moore: Believe in better Dr A. Shakir Dr S. Hassan Dr Gangasani: Aﬁb Dr James MarOn: Dr Batra: Director Dr Azoury Aﬁb/Lead ExtracOons