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Atrial Fibrillation: Update 2007

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1 Atrial Fibrillation: Update 2007
David L. Scher, FACP, FACC, FHRS Director, Cardiac Electrophysiology Pinnacle Health System and Associated Cardiologists, PC Harrisburg, PA Clinical Associate Professor of Medicine Pennsylvania State College of Medicine October 13, 2007

2 Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis. 6% PSVT 6% PVCs 18% Unspecified 4% Atrial Flutter 9% SSS 34% Atrial Fibrillation 8% Conduction Disease 10% VT 3% SCD 2% VF Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

3 Classification Paroxysmal: recurrent (>2 episodes) that terminate spontaneously within seven days. Persistent: AF with duration greater than seven days, or requiring CV (drugs or electrical). Also includes “longstanding persistent AF” (continuous AF lasting greater than one year). Permanent: AF in which decision not to restore SR by any means is made.

4 Atrial Fibrillation: Cardiac Causes
Hypertensive heart disease Ischemic heart disease Valvular heart disease Rheumatic: mitral stenosis Non-rheumatic: aortic stenosis, mitral regurgitation Pericarditis Sinus node dysfunction Cardiomyopathy Hypertrophic Idiopathic dilated (? cause vs. effect) Post-coronary bypass surgery

5 Atrial Fibrillation: Non-Cardiac Causes
Pulmonary COPD Pneumonia Pulmonary embolism Metabolic Thyroid disease: hyperthyroidism Electrolyte disorder Acidemia, sepsis, other hyperadrenergic states Toxic: alcohol (‘holiday heart’ syndrome)

6 AF: Pathophysiology Wavelets

7 AF: Pathophysiology Wyse and Gersch, Circulation, 2004;109:

8 AF: Pathophysiology Wyse and Gersch, Circulation, 2004;109:

9 Why Treat AF? Wyse and Gersch, Circulation, 2004;109:

10 2006 ACC/AHA/ESC Practice Guidelines: Changes Since 2001 Guidelines
Incorporation of major clinical trials. Reorganized with emphasis on clinical patient management. Incorporation of catheter-based ablation technologies. Drug therapy: those approved in N. America and Europe Emerging importance of angiotensin inhibition. Prophylactic therapies. JACC 2006, 48:e

11 Rate Control vs. Rhythm Control
Studies AFFIRM (2002) RACE (2002) PAF (2000) STAF (2003) HOT CAFE’ (2004) No study demonstrated a difference in quality of life!

12 Rate Control vs. Rhythm Control
However, judgment should be exercised in applying this lack of difference of QOL to individual patients! Definition of rate control: less than 100 bpm over at least 18 hr monitoring period, or less than 100% of maximum age-adjusted predicted exercise heart rate. Regardless of treatment strategy, antithrombotic therapy is to be continued in indicated patients!

13 Clinical Management

14 Clinical Management

15 Clinical Management

16 Clinical Management: Which AA Drug?

17 Catheter and Surgical Ablation of AF

18 Atrial Fibrillation Ablation: HRS/EHRA/ECAS Expert Consensus Statement
Electrophysiologic basis and rationale Patient Selection Methods Complications Appropriate follow-up and long-term management

19 Ablation: Electrophysiologic Basis
Traditional Theory: Wavelets

20 Previous Next    Volume 339:      September 3, 1998 Number 10 Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Philippe Le Métayer, M.D., and Jacques Clémenty, M.D

21 Embryology of the Pulmonary Veins

22 Pulmonary Veins

23 Catheter Ablation of AF: Different Approaches

24 Patient Selection Symptomatic AF refractory or intolerant to at least one Class 1 or class 3 antiarrhythmic drug. Only absolute contraindication: LA thrombus (TEE before ablation in pts. with persistent AF). Other considerations: Success less likely in pts. with marked LA dilatation. Higher complication rate in very elderly. Pts.’ desire to discontinue warfarin is not an appropriate sole indication for ablation.

25 Complications Cardiac tamponade Pulmonary vein stenosis
Atrio-esophageal fistula Phrenic nerve injury Thromboembolism

26 Complications Air embolism Post-procedural arrhythmias
Vascular complications Acute coronary occlusion Periesophageal vagal injury

27 Appropriate Follow-up and Long-Term Management: Areas of Consensus
IV or LMW heparin bridging. Warfarin for at least 2 months in all patients. Decision re: warfarin after 2 months based on pt. risk factors NOT presence or absence of AF. Long-term warfarin for pts. With CHADS > 2.

28 Appropriate Follow-up and Long-Term Management: Areas of Consensus
Repeat procedures: to be deferred for at least 3 months, if symptoms can be controlled with drugs. Definition of major complication: permanent injury, death, requiring intervention for treatment, or prolong or require hospitalization.

29 Appropriate Follow-up and Long-Term Management: Areas of Consensus
Definition of success: freedom from AF/flutter/tachycardia is primary endpoint. Has varied: freedom for AF w/ and w/o sx, 90% reduction of AF burden, presence of AA drugs. Recurrence defined as AF/flutter/tachycardias documented lasting > 30 seconds (does not include early recurrence blanking period of 3 months). Early recurrence common and not failure: 35%, 40%, 45% at 15, 30, and 60 days respectively. Late recurrence (> 1 yr): 5-10%.

30 Appropriate Follow-up and Long-Term Management: Areas of Consensus
Minimal monitoring: office F/U 3 months post ablation and Q 6 mos. for 2 yrs. Event recorder monitoring for palpitations. 24-hour Holter monitoring at 3-6 mo. intervals for 1-2 yrs for clinical trials.

31 Literature Review: Non-randomized trials
Single procedure success, %: Paroxysmal AF: >60 (38-78) Persistent: <30 (22-45) Mixed: 16-84 Multiple procedure success, %: Paroxysmal: >70, (37-88) Persistent: >50 (37-88) Mixed:

32 Literature Review: 5 Randomized trials
2005:70 pts randomized flecainide/sotalol or ablation: recurrence= AF w/ or w/o sx. AA: 63% Abl: 13% 2006: (146 pts) Persistent AF CV vs. ablation: Recurrence: freedom from AF/AFL w/o drugs. CV: 58% Abl: 74%

33 Literature Review: 5 Randomized trials
2006: (137 pts) Prospective: Role of abl as adjunctive Rx: Recurrence: AA: 81%, ablation + AA: 45% 2006: (199 pts) Randomized, prospective: AA vs ablation: Recurrence: AA: 78%, ablation: 14% 2006: (112 pts) AA vs ablation: Recurrence: AA: 93%, ablation: 25% 63% of AA pts crossed over to ablation

34 Catheter Ablation of AF
J Cardiovasc Electrophysiol. 2006;17:1-6

35

36

37 Surgical Ablation of AF
Concomitant to other open heart operations. Stand alone surgery for AF.

38 Surgical Ablation of AF: Concomitant to other open heart operations
Rationale: AF is an independent predictor of late mortality. AF associated with higher periop mortality. Majority of pts with persistent AF before surgery remain unless treated at time of surgery.

39 Surgical Ablation of AF: Concomitant to Other Open Heart Operations
Involves cryoablation, mocrowave, or RF ablation isolation of pulmonary veins and LA lesions (including line to MV-LA isthmus). Results: 76%success with LA isthmus lesions, 29% without (mean F/U 41 mos). LA appendage occlusion should be strongly considered. Results highly variable depending on energy source and completeness of ablation lines.

40 Stand-alone Surgical Ablation
Surgical Maze Procedure Cox JL et al. Ann of Surgery 1996;224(3):

41 Cox MAZE III Procedure Cox JL et al. Ann of Surgery 1996;224(3):

42

43

44

45 Bipolar clamp ablation

46 Gross Pathology Atrial Appendage
Above, a lesion created with the AtriCure system is shown on the epicardial surface of an atrial appendage. Lesions created with the AtriCure system are typically very narrow and discreet in nature. When the atrial appendage is invaginated, the endocardial lesion is seen. The electrodes of the AtriCure Handpiece never came in contact with this endocardial surface.

47 Stand-alone Surgical Ablation of AF

48 Thromboembolic Risk: Pathophysiology
Wyse and Gersch, Circulation, 2004;109:

49 Thromboembolic Risk Stratification: Who Needs Anticoagulation?

50 Thromboembolic Risk Stratification: Who Needs Anticoagulation?

51 Thromboembolic Risk Stratification: Who Needs Anticoagulation?

52 Thromboembolic Risk Stratification: Who Needs Anticoagulation?

53 SUMMARY AF is the most common arrhythmia for which pts. are hospitalized. AF is associated with an icreased risk of morbidity and mortality. Rhythm control is not necessary in older pts. with minimal or absence of symptoms. AA drugs should be chosen based on side effect and proarrhythmic potential, not efficacy (except amio). Catheter and surgical ablation are effective in symptomatic pts. unresponsive to medical Rx. Antithrombotic therapy guidelines should be followed.


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