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….

2.4% of the total NHS budget 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

Current success rates 80% The procedure works….. Current success rates 80%

in long standing persistent AF too.. Redo AAD therapy Results Complications Haissaguerre JCE 2005 60 1/2 Stopped at ablation 95% at 11 months 2 Tamponades Oral NEJM 2006 77 1/3 Amio 6/52 pre & 3/12 post 77% at 1 year Postch Circ 2008 88 81% at 20 months 1 TIA Lo JCE 2009 87 1/4 AAD 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!

Drugs Ablation 30% efficacy 80% chance of cure Life long suffering One-stop solution

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

Finally... What would you want?!