AF Ablation in 2015 Why, Who, What and How? Steve Wilton ACC Rockies, Banff March 10, 2015
Disclosures Research grant: St. Jude medical Speaking: Boehringer-Ingelheim Consulting: Arca Biopharma
Learning Objectives Why? Indications for AF ablation Who? Review patient selection What? Review ablation strategies How? Explore new technologies
The AF Epidemic Framingham Lloyd-Jones, Circulation, 2004
Why? Goals of AF ablation Reduce AF symptoms (improve QoL) Eliminate antiarrhythmic drugs Decrease stroke risk? Prevent/reduce heart failure? Reduce hospitalizations? Improve survival? Avoid anticoagulation?
CCS Rate -Rhythm control algorithm Verma, CJC, 2015
Indications - ACC/AHA AF Guideline Symptomatic patients with Class Level Paroxysmal AF, failed 1 antiarrhythmic drug I A Paroxysmal AF, first line IIa B Persistent AF <1yr, failed 1 antiarrhythmic IIa A Persistent AF 1 yr, failed 1 antiarrhythmic IIb B January, Circ, 2014
AF Ablation first line? 1.0 Cumulative Hazard Rate 0.8 Antiarrhythmic drug 0.6 Radiofrequency catheter ablation 0.4 0.2 HR, 0.56, 95% CI, 0.33-0.95, P =.03 0.0 0 91 182 273 364 455 546 637 728 Follow-up Since Randomization, d 61 61 40 32 28 25 24 24 18 66 66 50 47 38 36 34 33 23 RAAFT-2, Morillo, JAMA, 2014
Patient Selection role of CHADS2 Chao, Heart Rhythm, 2011
Imaging for patient selection Marrouche, JAMA, 2014
Imaging for patient selection Marrouche, JAMA, 2014
Role of Lifestyle Modification BMI 27, 1 risk factor Pre-ablation opt-in Weight loss (10%) BP control Lipid control OSA assessment/tx ARREST AF Cohort: Sanders, JACC, 2014
What? Calkins, HRS Consensus, 2012
What? Calkins, HRS Consensus, 2012
PAF: Circumferential PVI
Paroxysmal vs. Persistent AF PAF Triggers & Drivers (PVs) Ps AF Abnormal Atrial Tissue Disease Progression Electrical Remodeling Structural Remodeling Fibrosis Inflammation
Stepwise Approach for Persistent AF 1. PV Isolation 2. Defragmentation 3. Linear Ablation LAA RSPV LSPV RIPV Isolation LIPV CS Local EGM organization Ø Roof Ø Mitral MA Conduction block Endpoint: Termination of AF (70-85%) Hocini M et al. J Am Coll Cardiol. 2010;55:1007-16. O Neill M et al. Eur Heart J. 2009;30:1105-12. Haissaguerre M et al. J Cardiovasc Electrophysiol. 2005;16:1125-37.
Stepwise Ablation: Long Term Multiple Procedure Results (median 2) Scherr, Circ AE, 2015
How? Technological Advances 1. Use the Force! Catheter tissue contact is critical Standard methods are all flawed Catheter feel Fluoro EGM size Impedance change
2. Freeze it: Cryoballoon Good tissue contact May reduce procedure time Results similar to radiofrequency Phrenic nerve palsy risk? Costs
3. Get smart: AF mapping Rotors: putative drivers of AF Previously not proven to exist in humans Narayan, JACC, 2012
Unanswered Questions Does AF ablation influence prognosis? CABANA, RAFT AF Does risk factor control improve outcomes? SMAC AF, others Can we stop OAC after successful ablation? OCEAN
Key messages Why? Primarily symptom control Ongoing trials will address prognosis Who? Patient selection evolving Don t forget lifestyle modification What? PVI for Paroxysmal Optimal strategy in Persistent AF unclear How? Rapid technological advances continue
Thanks!