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Christopher L. Fellows, MD, FACC, FHRS Virginia Mason Medical Center Seattle, Wa. Atrial Fibrillation 2014.

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Presentation on theme: "Christopher L. Fellows, MD, FACC, FHRS Virginia Mason Medical Center Seattle, Wa. Atrial Fibrillation 2014."— Presentation transcript:

1 Christopher L. Fellows, MD, FACC, FHRS Virginia Mason Medical Center Seattle, Wa. Atrial Fibrillation 2014

2 1)2014 AHA/ACC/HRS Guidelines for the Management of AF 2) 2011 Focused Update on the management of AF 3)2012 Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation

3 AF is very frustrating Causes strokes…strokes are BAD Makes pts feel BAD Therapy toxic and ineffective

4 There are 3 reasons to treat AF…

5 Stroke Risk in Patients With Nonvalvular AF Not Treated With Anticoagulation According to the CHADS 2 Index CHADS 2 Score Stroke Rate %per year

6 CHADS2 CHADS2 VASC CHF Hypertension Age > 75 Diabetes Stroke/TIA (2) CHF/LV dysfunction Hypertension Age > 75 (2) Diabetes Stroke/TIA/TE (2) Vasc disease Age > 65 Sex (female) Gage BF JAMA 285: ,2001Lyp GYH Chest 137: ,2010

7 Is Sinus Rhythm Important ? AFFIRM (Wyse DG, et.al. NEJM 2002;347: ) RACE (Hagens VE, et.al. JACC 2004;43: ) STAF (Carlsson J, et.al. JACC 2003;41: ) All concluded …..that there were no mortality differences between rate control and rhythm control strategies in the treatment of AF

8

9 Sinus Rhythm AFFIRM type trials excluded highly symptomatic patients Trials designed to test strategy not therapy Therapy was very ineffective

10 AFFIRM Substudy On treatment analysis NSR= 47% lower risk of death AAD use = 49% increased risk of death AFFIRM investigators. Circ 2004;109:

11 “…the failure of AFFIRM, RACE, or STAF in showing any differences between rate and rhythm control is not so much a positive statement for rate control but rather a testimony on the ineffectiveness of the rhythm control methods used.” Verma A, Natale A. Circulation 2005;112:

12 OK, Sinus rhythm is good but at what price ? Drugs Pacer ICD Ablation

13 Time (days ) Sinus Rhythm (%) Roy et al. NEJM 2000;342: Amiodarone Propafenone Sotalol Antiarrhythmic Drugs

14 AF drugs…my best guess Betablockers Flec/Propaf Sotalol Amio/Dofet Dronedarone Ca blocker Dig Everybody Lone AF Good LV Bad LV Good LV Rate control CHF only

15 OK, Sinus rhythm is good but at what price ? Drugs Pacer ICD Ablation

16 Haissaguerre et al.NEJM 1998;339:

17 Kaplan-Meier Curves of Time to Protocol-Defined Treatment Failure, Recurrence of Symptomatic Atrial Arrhythmia, and Recurrence of Any Atrial Arrhythmia by Treatment Group Wilber, D. J. et al. JAMA 2010;303:

18 “… the success of Pulmonary Vein Antral Isolation can exceed 90%, sometimes requiring 2 procedures, and there is an associated risk of stroke <1%, cardiac perforation <1%, pulmonary vein stenosis <1%, vascular injury <1%, and atrioesophageal fistula 1/1000.”

19 Results Worldwide data* (100 centers), 52% efficacy (27% repeats) 6% complications US data** (92 centers) 66% efficacy *Cappato R, Calkins H, Chen S et.al Circ. 2005;111: **Mickelson S, Dudley B, Treat E, et.al. JICE 2005;12:

20 Published Catheter Ablation Success Rates Success Rates Catheter Ablation Calkins H, et al. Circulation. 2009;2: N = 63 studies 6936 pts Major complications 4.9%

21 Cryoablation 1948 (Hass) surgical Cryo lesions in Cardiac surgery using CO (Cooper) developed liquid nitrogen surgical cryo tools 1977 (Gallagher) reported AVN ablation using surgical cryoablation 1991 (Gillette) cryoablation catheter in animals 1999 (Dubuc) cryocatheter in humans

22 22 Cryoablation Preserves endothelial integrity 1 Decreases risk of thrombus formation 1 1 Sarabanda AV, et al. J Am Coll Cardiol. 2005;46:

23 23 Treatment Success Effectiveness Results Freedom from AF after 90 Days Blanked for Detectable AF CRYO 69.9% (114 / 163) DRUG 7.3% (6 / 82) OR = 29.5 (12.0 – 72.2) p < Blanked for Detectable AF

24 Cryoballoon results 2/11 – 10/14 (CF) N=595 (male 72%) Ages All symtomatic, documented multiple AF episodes, failed drug therapy. 82/410 prior failed procedures (8 surgical Maze, 10 multiple RF failures)

25 Cryoballoon results 2/ / patients >1 yr f/u 90% NSR, (77% 95/124 NSR off drugs).

26 Advance Balloon f/u > 12 mo 50 pts ablated between 6/12 and 11/12 47/50 f/u data available 39/47 cured (no AF no AAD) (83%) 4/47 brief AF no AAD 2/47 no AF remain on AAD 2/47 failures (4%) 96 %

27 Immediate Lab Complications (18/595 = 3%) 7 groin hematoma (1.1%) (no intervention required) 2 hypotension/acidosis 1 hyperkalemia 1 phenylepherine IV extravasation 2 hematuria from foley placement 1 ileus 1 temporary pacing overnight for bradycardia 1 cath/stent 2 CHF exacerbation

28 Phrenic nerve palsy (N=595) 44 Phrenic nerve palsy (7.4%) 40 transient with full recovery in lab. 4 persistent at discharge, 3 with full recovery by 3 months, 1 recovery in 12 months.

29 Late Complications (N=595) 0 CVA,TIA,MI, or embolism 0 Tamponade 0 EA fistula 0 Deaths 0 persistent phrenic nerve palsy (1 yr)

30 “… the success of Pulmonary Vein Antral Isolation can exceed 90%, sometimes requiring 2 procedures, and there is an associated risk of stroke <1%, cardiac perforation <1%, pulmonary vein stenosis <1%, vascular injury <1%, and atrioesophageal fistula 1/1000.”

31 Repeat Procedures 25 %-33% with RF 34/595 (5.7%) with Cryo

32 Goals Improve efficacy Decrease complications Decrease repeat procedures Minimize iatrogenic arrhythmias ( LA flutter) Decrease lab time or minimize variability

33 Total Lab Time

34 Long-term Outcomes N= 605 (579 PAF) month f/u ( median 30 month) 61.6% single procedure 74.9% multiple procedure PNP 2% ( last 420 patients 0.7%) Vogt J, et al. JACC 2013;61:

35 CRYO Procedure Experience Impacts Treatment Success 25 center s n=43 P < by quartile 14 center s n=38 10 Center n=42 4 center s n=40 1 st and 2 nd procedures 3 rd – 5 th procedures 6 th – 11 th procedures 12 th – 23 rd procedures 100% 80% 60% 40% 20% 0% Treatment Success 56% 66% 69% 90%

36 AF Ablation The “Cure”….where are we ? The concepts are good The tools are getting better Current techniques are becoming more practical for widespread application Safety remains a concern

37 AF ablation remains a second line therapy for highly symptomatic patients who fail medical management or cannot /will not take medications (2006) or first line therapy for selected patients (2011)

38 Things to consider This is great for symptomatic paroxysmal AF It is a 2 hour procedure under a general anesthetic Requires anticoagulation with warfarin It does not change your CHADS score It doesn’t work in everybody There are serious potential complications


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