Presentation on theme: "AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital."— Presentation transcript:
AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital
AF ablation is a waste of time and money: (you must be joking!) Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital
A recap of what we’ve learnt this morning….
AF kills you (slowly)….
AF makes you miserable….
AF costs megabucks…. 2.4% of the total NHS budget
Conventional treatments limited efficacy Drugs only work in 1 in 3 patients
Not only are drugs potentially ineffective but….. They often cause unacceptable side effects Discontinuation rates due to Adverse Effects: CTAF: 18% Amio, 11% Sotalol AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide They may increase mortality SPAF: esp. in heart failure AFFIRM: AAD associated with mortality (p=0.0005)
Dronedarone isn’t the answer…. Mild antiarrhythmic action AF recurrence at 1 year: 64% vs 75% for Placebo << Amiodarone (free from AF at 6 mo: 37% vs 58%) Increased mortality in Heart Failure (ANDROMEDA) Only approved by the NICE with reservations
….and neither is cardioversion
Finally, a cure is in sight! Culprit: triggers in pulmonary veins
Treatment: Pulmonary Vein Isolation
The procedure works….. Current success rates 80%
in long standing persistent AF too.. NRedoAAD therapyResultsComplications Haissaguerre JCE /2Stopped at ablation 95% at 11 months 2 Tamponades Oral NEJM /3Amio 6/52 pre & 3/12 post 77% at 1 year 0 Postch Circ /2Stopped at ablation 81% at 20 months 2 Tamponades 1 TIA Lo JCE /4AAD for 2/12 post 79% at 21 months 1 Tamponade
It’s clearly better than drug therapy
AF ablation has evolved rapidly… Success rates have doubled Paroxysmal AF: 40-50% to 80-90% Persistent AF: 30-40% to 70-80% Procedure times have halved From 4-6 hours to 2-3 hours Complication rates have halved: 4% to 2%
Current technology has improved accuracy
The last thing we now need is a party pooper!
Ablation 80% chance of cure One-stop solution Drugs 30% efficacy Life long suffering
If you always do what you always did…you’ll always get what you’ve always got
Yes, AF ablation costs money… 100,000 AF cases a year Median 1.5 procedures £4000 per ablation Total cost: half a billion pounds
But where would you rather spend this money? ? Iraq War: £ 4.5 billion (Mar 2006) ? Olympics: £9.8 billion ? NHS IT project: £15 billion ? Bank Bailout £850 billion
Upfront costs outweighed by subsequent savings… Costs of recurrent hospital admissions Electrical cardioversions Absences from work Costs of lifelong drug therapy Regular INR tests Decreased risk of the serious AF sequalae Stroke Heart Failure
Measures to make ablation more cost effective 1. Careful patient selection: ablation not offered Very long standing Persistent AF (>3 years) Very large LA (>5.5 cm) Morbid Obesity (BMI >40) Age >80 years Significant co-morbidity
Measures to make ablation more cost effective 2. Individualised ablation strategy: Improve single procedure success rates Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010