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Atrial fibrillation:
Who should be referred for
ablation therapy for atrial
fibrillation?.
September 12th , 2015
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Sohail Hassan MD FACC, FHRS Director, Cardiac Electrophysiology St John Hospital, Detroit MI Assistant Professor of Medicine Wayne State University Believe in better
Atrial fibrilla/on: WHO HAS IT? G Bush Senior: VP Joe Biden Lary Bird Howie Mandel Believe in better
VP Dick Chene Elton John Barry Manilow Hakim Elijuan Believe in better
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GOALS OF
THERAPY
•  Prevent stroke
Anticoagulation
•  Relieve symptoms
Rate control
Maintain sinus rhythm
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Five things to remember for a pt with
atrial fibrillation
•  Figure out why pt in afib.
–  Careful BP assessment
–  Physical exam
–  Echocardiogram LV function and LA size.
–  TSH, Sleep study.
•  Figure out extent of symptoms/disability
–  SAF Class (0-4)
•  Calculate stroke risk CHADS2 VASC score.
•  Start with rate control.
•  Consider referral if symptomatic. If asymptomatic
STILL AN EVALUATION BY A CARDIOLOGIST
AND AN ELECTROPHYSIOLOGIST IS
INDICATED.
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Young Patient with Atrial fibrillation
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•  40 yr old male
•  Seen in ED with new onset palpitations
–  Started 2 hrs ago. One episode a month
with dizziness lasting 2 hours.
–  BP is 150/80
–  Echo LA dimension is 5.0 cm. ef wnl, no
MR
•  Otherwise healthy but nervous
•  ECG: atrial fib 160
–  Rx’d with beta blocker: HR 85. cardiologist/
EPS starts pt on Propafenone 150mg
tid>>titrated up…to 225tid
–  Feels much better for one year and now
symptoms are back..
–  IS HE A GOOD CANDIDATE FOR
ABLATION THERAPY
AF Catheter Abla/on to Maintain Sinus Rhythm Believe in better
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Recommendations
COR LOE
AF catheter ablation is useful for symptomatic
paroxysmal AF refractory or intolerant to at least 1
I
A
class I or III antiarrhythmic medication when a
rhythm-control strategy is desired.
Before consideration of AF catheter ablation,
assessment of the procedural risks and outcomes
I
C
relevant to the individual patient is recommended.
AF catheter ablation is reasonable for some
patients with symptomatic persistent AF refractory
IIa
A
or intolerant to at least 1 class I or III
antiarrhythmic medication.
In patients with recurrent symptomatic
paroxysmal AF, catheter ablation is a reasonable
initial rhythm-control strategy before therapeutic
IIa
B
trials of antiarrhythmic drug therapy, after
weighing the risks and outcomes of drug and
ablation therapy.
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CASE NO 2. 65 yr. old asymptomatic male
with atrial fibrillation, holter shows 24 hours
of constant atrial fibrillation.
•  Diagnosed when pt was referred for
screening colonoscopy.
•  Only comorbidity is HTN and sleep apnea.
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1.  SHOULD we be worried about atrial
fibrillation?
2.  Is this pt at risk of stroke? YES
3.  Should he Undergo ablation therapy?
SHOULD we be worried about atrial
fibrillation?
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AF Catheter Abla/on to Maintain Sinus Rhythm (cont’d) Believe in better
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Recommendations
AF catheter ablation may be considered for
symptomatic long-standing (>12 months)
persistent AF refractory or intolerant to at least 1
class I or III antiarrhythmic medication when a
rhythm-control strategy is desired.
AF catheter ablation may be considered before
initiation of antiarrhythmic drug therapy with a
class I or III antiarrhythmic medication for
symptomatic persistent AF when a rhythm-control
strategy is desired.
AF catheter ablation should not be performed in
patients who cannot be treated with anticoagulant
therapy during and after the procedure.
AF catheter ablation to restore sinus rhythm
should not be performed with the sole intent of
obviating the need for anticoagulation.
COR LOE
IIb
B
IIb
C
III:
Harm
C
III:
Harm
C
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Does atrial fibrillation ablation
decrease the risk of stroke?
•  Studies are mainly focused on pt with low
to moderate risk of stroke when
anticoagulation were stopped after
ablation.
•  The largest study was performed by
Reynolds et al.7 Over a 3-year follow-up,
they reported an annual stroke risk of
1.6% for patients after AF ablation and
2.7% on antiarrhythmic drugs.
Reynolds MR, Gunnarsson CL, Hunter TD, et al. Health outcomes with catheter ablaOon or anOarrhythmic drug therapy in atrial fibrillaOon: results of a propensity-­‐matched analysis. Circ Cardiovasc Qual Outcomes. 2012;5(2):171-­‐181. Believe in better
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CASE 3
•  76 YR OLD GENTLEMAN WITH
PERSISTENT A FIB, PLAYS TENNIS
COMPLAINS OF FATIGUE. TWO
ENDOVASCULAR ABLATIONS FOR
ATRIAL FIBRILLATION…SEVERELY
SYMPOMATIC.
•  HTN EF IS 55% . LA SIZE IS 5.0 CM.
•  IS THERE ANOTHER OPTION FOR THIS
PT.
Reynolds MR, Gunnarsson CL, Hunter TD, et al. Health outcomes with catheter ablaOon or anOarrhythmic drug therapy in atrial fibrillaOon: results of a propensity-­‐matched analysis. Circ Cardiovasc Qual Outcomes. 2012;5(2):171-­‐181. Believe in better
Surgical Maze Procedures Believe in better
Recommendations
An AF surgical ablation procedure is reasonable
for selected patients with AF undergoing cardiac
surgery for other indications.
A stand-alone AF surgical ablation procedure may
be reasonable for selected patients with highly
symptomatic AF not well managed with other
approaches.
COR LOE
IIa
C
IIb
B
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St John Arrhythmia Management team: Dr D. Moore: Believe in better
Dr A. Shakir Dr S. Hassan Dr Gangasani: Afib Dr James MarOn: Dr Batra: Director Dr Azoury Afib/Lead ExtracOons Believe in better
Atrial fibrillation:
Who should be referred for
ablation therapy for atrial
fibrillation?.
September 12th , 2015
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Sohail Hassan MD FACC, FHRS Director, Cardiac Electrophysiology St John Hospital, Detroit MI Assistant Professor of Medicine Wayne State University