1. Risk Factor Modification
ABLATE AF
The sooner the Better
Oussama Wazni, MD MBA Professor of Medicine Section Head, Clinical Cardiac EP Cleveland Clinic
Diagnose
Ablate Early
Followup
Risk Factor Modification

2. AF BEGETS AF
J Coll Card 2008 Jun 3, 51 (22):2161

3. Diclosures
Boston Scientific
BWI
PI for STOP AF FIRST

4. Journal of the American College of Cardiology Volume 63, Issue 17, May 2014 Lone Atrial Fibrillation Does it Exist?D. George Wyse, et al

5. Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)

6. Conceptual framework of atrial fibrillation (AF) initiation, maintenance, and progression.
Jordi Heijman et al. Circ Res. 2014;114:
Copyright © American Heart Association, Inc. All rights reserved.
Conceptual framework of atrial fibrillation (AF) initiation, maintenance, and progression. A, In patients with a sufficiently large genetic predisposition, AF onset may occur at a relatively young age. AF-induced remodeling helps to maintain the arrhythmia, as well as promoting AF progression. B, In most patients, the genetic substrate alone does not provide sufficient susceptibility for AF. Additional disease-related remodeling may increase vulnerability and allow the initiation of paroxysmal AF episodes. Over time, some patients with paroxysmal AF may progress to longer-lasting persistent AF forms. C, Because of the composition of substrate and trigger, some patients have a first AF episode lasting >7 d and may progress to permanent AF due either to progression of underlying disease or to a medical decision to leave the patient in AF. (Note that for convenience the time scale for AF episodes, in gray, is expanded compared with the lower axis providing a sense of lifetime time course.)‏

7. Circ Arrhythm Electrophysiol. 2018
low progression rate of 6.2% to persistent over 10 years
Scardi et al 34% rate to persistent AF over 10 years
Kato et al progression rate 77.2% (5.5%/y) over 14-year
Canadian Registry, evaluated 757 patients and found a progression rate of 8.6%/y and 24.7% after 5 years
Roland Richard Tilz, et al Karl-Heinz Kuck, Feifan Ouyang,

9. First-diagnosis to ablation time quartiles, years
Radiofrequency Ablation of Persistent Atrial Fibrillation: Earlier Ablation is associated with Better Outcomes in Direct Association with Markers of Pathways of Atrial Remodeling
First-diagnosis to ablation time quartiles, years
Variable patients
All patients ≤1
>6.5
p-value N
1241
382
287
268
304
ContinuousAF>12 months
17.3
5.2
19.6
19.9
28.2
0.0001
Age, years
61.0±10.2
60.9±10.4
60.9±9.7
60.7±10.2
61.4±10.3
0.9
Male gender
78.5
78.3
77.0
75.8
82.6
0.2
Coronary disease
20.1
18.6
23.5
19.4
0.4
Hypertension
38.5
31.7
33.8
45.9
45.1
<0.0001
Diabetes mellitus
8.5
6.5
9.4
9.0
9.5
LVEF, %
52.3±9.4
52.4±9.1
52.1±9.5
52.3±9.3
52.3±9.8
Left atrial size, cm2
26.7±6.3
25.5±5.3
26.8±7.7
26.9±6.0
27.4±6.0
0.03
hs-CRP, mg/L
1.8
( )
1.5
( )
(0.8-4)
2.3
( )
2.1
( )
BNP, pg/mL
117
(66-191)
104
(58-175)
122
(67-207)
116
(62-203)
126
(80-189)
0.01

10. Radiofrequency Ablation of Persistent Atrial Fibrillation: Earlier Ablation is associated with Better Outcomes in Direct Association with Markers of Pathways of Atrial Remodeling

11. Radiofrequency Ablation of Persistent Atrial Fibrillation: Earlier Ablation is associated with Better Outcomes in Direct Association with Markers of Pathways of Atrial Remodeling

12. Radiofrequency Ablation of Persistent Atrial Fibrillation: Earlier Ablation is associated with Better Outcomes in Direct Association with Markers of Pathways of Atrial Remodeling

13. Radiofrequency Ablation of Persistent Atrial Fibrillation: Earlier Ablation is associated with Better Outcomes in Direct Association with Markers of Pathways of Atrial Remodeling

15. Five-Year Outcome of Catheter Ablation of Persistent Atrial Fibrillation Using Termination of Atrial Fibrillation as a Procedural Endpoint
Bordeaux Grp Circ EP 2015

16. 493 Patients
Hamburg Group Circ EP 2015

17. STAR AF II

21. STOP AF FIRST Study Design:
210 subjects at 30 sites in the United States.
Subjects are randomized 1:1 to either the treatment arm or control arm.
Treatment Arm: Pulmonary vein isolation ablation using the Arctic Front Advance™ Cardiac CryoAblation Catheter. This treatment is investigational because the catheter is not indicated for use in subjects unless they fail an antiarrhythmic drug first.
Control Arm: Treatment with Class I or III antiarrhythmic drugs.

23. Conclusion
Ablate Early Aim for durable isolation Ablate any identifiable triggers Substrate modification

24. Conclusion

25. GLOBAL EP SUMMIT CLEVELAND
September 27th and 28th, 2019
Thank

26. Thank You