Presentation on theme: "Atrial Fibrillation: Update 2007"— Presentation transcript:
1Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRSDirector, Cardiac ElectrophysiologyPinnacle Health System and Associated Cardiologists, PCHarrisburg, PAClinical Associate Professor of MedicinePennsylvania State College of MedicineOctober 13, 2007
2Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.6% PSVT6% PVCs18% Unspecified4% Atrial Flutter9% SSS34% Atrial Fibrillation8% Conduction Disease10% VT3% SCD2% VFData source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
3ClassificationParoxysmal: 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.
4Atrial Fibrillation: Cardiac Causes Hypertensive heart diseaseIschemic heart diseaseValvular heart diseaseRheumatic: mitral stenosisNon-rheumatic: aortic stenosis, mitral regurgitationPericarditisSinus node dysfunctionCardiomyopathyHypertrophicIdiopathic dilated (? cause vs. effect)Post-coronary bypass surgery
7AF: PathophysiologyWyse and Gersch, Circulation, 2004;109:
8AF: PathophysiologyWyse and Gersch, Circulation, 2004;109:
9Why Treat AF?Wyse and Gersch, Circulation, 2004;109:
102006 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 EuropeEmerging importance of angiotensin inhibition.Prophylactic therapies.JACC 2006, 48:e
11Rate Control vs. Rhythm Control StudiesAFFIRM (2002)RACE (2002)PAF (2000)STAF (2003)HOT CAFE’ (2004)No study demonstrated a difference in quality of life!
12Rate 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!
18Atrial Fibrillation Ablation: HRS/EHRA/ECAS Expert Consensus Statement Electrophysiologic basis and rationalePatient SelectionMethodsComplicationsAppropriate follow-up and long-term management
19Ablation: Electrophysiologic Basis Traditional Theory: Wavelets
20PreviousNext Volume 339:September 3, 1998Number 10Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary VeinsMichel 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
24Patient SelectionSymptomatic 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.
27Appropriate 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.
28Appropriate 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.
29Appropriate 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%.
30Appropriate 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.
32Literature 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%
33Literature 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
34Catheter Ablation of AF J Cardiovasc Electrophysiol. 2006;17:1-6
37Surgical Ablation of AF Concomitant to other open heart operations.Stand alone surgery for AF.
38Surgical 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.
39Surgical 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.
40Stand-alone Surgical Ablation Surgical Maze ProcedureCox JL et al. Ann of Surgery 1996;224(3):
41Cox MAZE III ProcedureCox JL et al. Ann of Surgery 1996;224(3):
46Gross 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.
48Thromboembolic Risk: Pathophysiology Wyse and Gersch, Circulation, 2004;109:
49Thromboembolic Risk Stratification: Who Needs Anticoagulation?
50Thromboembolic Risk Stratification: Who Needs Anticoagulation?
51Thromboembolic Risk Stratification: Who Needs Anticoagulation?
52Thromboembolic Risk Stratification: Who Needs Anticoagulation?
53SUMMARYAF 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.