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Venice Arrhythmias 2015 SILENT ATRIAL FIBRILLATION: TO TREAT OR NOT TO TREAT After Catheter Ablation Dr Sakis Themistoclakis Head, Unit of Electrophysiology and Cardiac Pacing Department of Cardiothoracic & Vascular Medicine Ospedale dell’Angelo, Mestre-Venice, Italy CONFLICTS OF INTEREST TO DISCLOSE: Consultant: Biosense Webster, Daiichi Sankyo Research Grant: • Bayer Pharma: X-VERT Trial (Local PI) • Biosense Webster: OAT Study (Steering Committee) • BMS/Pfizer: AEGEAN Trial (Local PI) • Daiichi Sankyo: ENSURE AF Trial (National PI, Steering Committee) • Boheringher Ingelheim: RE-CIRCUIT Trial (National PI) • AF-NET, BMS/Pfizer: AXAFA Trial (National PI) Speaker Honoraria: Bayer Pharma, Boheringher Ingelheim, Daiichi Sankyo Treatment of Atrial Fibrillation With Antiarrhythmic Drugs or Radiofrequency Ablation Efficacy of RF catheter ablation: included studies with more than 40 pts 57% 71% 72% 77% Calkins et al. Circ Arrhythmia Electrophysiol. 2009;2:349-361 Very Long-Term Efficacy of AF Ablation Raviele et al. J Cardiovasc Electrophysiol 2012;23: 890-923 True very late recurrences or Recurrences underestimated during the follow up Asymptomatic AF Intensity of follow-up strategy & AF detection rate: Kircher S et al. Cur Cardiol Rev 2012; 8: 354-61 Asymptomatic AF Detection Methods: • Standard-12 lead ECG • • • • • • 24-h / 7-d Holter monitoring In-hospital telemetry Mobile continuous outpatient telemetry Event recorder / Intermittent TTEM PM - ICD Device memory External & Implantable loop recorder Relative AF duration in % of total recording during 7-day ECG Kottkamp et al. J Am Coll Cardiol 2004;44:869–77 AF freedom with comparison of 24-h Holter versus 7-day ECG & percentage of pts on AAD 24-h ECG 7-day ECG Kottkamp et al. J Am Coll Cardiol 2004;44:869–77 Time course of relative distribution of length of individual AF episodes in pts with recurrent AF AF episodes >24 h: 1/33 (3%) of patients Closed bars>24 h; hatched bars: >2 to 24 h; open bars: 30 s to 2 h Kottkamp et al. J Am Coll Cardiol 2004;44:869–77 Symptomatic and asymptomatic AF duration during the 7-day Holter monitoring Hindricks et al. Circulation 2005;112:307-13 Symptomatic and asymptomatic AF duration during the 7-day Holter monitoring Hindricks et al. Circulation 2005;112:307-13 Symptomatic and asymptomatic AF duration during the 7-day Holter monitoring Use of beta-blockers and antiarrhythmic drugs during SR: Hindricks et al. Circulation 2005;112:307-13 clotting time of 200 to 250 s). The electromagnetic mapping Table 1. Clinical Characteristics of the Study Patients (n " 100) circular lesion with the MA (so-called left atrial isthmus). (B) Posteroanterior view of an electroanatomic reconstruction of the left atrium, including the PV. Dark red dots represent ablation lines as described above. LAA " left atrial appendage; LLPV " left lower PV; LUPV " left upper PV; RLPV " right lower PV; RMPV " right middle PV; RUPV " right upper PV. Ablation strategy: No PVI Age, yrs Male, n (%) Paroxysmal AF, n (%) Persistent AF, n (%) AF history, yrs Antiarrhythmic drugs, n Arterial hypertension, n (%) Coronary artery disease, n (%) Valvular heart disease or CM, n (%) Diabetes mellitus, n (%) Lone AF, n (%) Left atrial diameter, mm LV ejection fraction, % No previous ablation attempt, n (%) Previous AF ablation or operation, n (%) Previous atrial flutter ablation, n (%) Previous other arrhythmia ablation, n (%) AF " atrial fibrillation; CM " cardiomyopathy; LV " left ventricular. 53 # 10 67 (67) 80 (80) 20 (20) 7.3 # 7.0 2.2 # 1.2 45 (45) 14 (14) 11 (11) 6 (6) 42 (42) 40 # 8 61 # 7 72 (72) 14 (14) 10 (10) 4 (4) system (Carto, Biosense Webster Inc., Diamond Bar, California) was used for reconstruction of the left atrium and navigation of the ablation catheter (Navistar, Biosense Webster Inc.). All PVs were visited with the mapping/ablation catheter and tagged. The vein-atrium transition was determined combining information from the fluoroscopic cardiac silhouette, impedance changes, and PV-atrium electrogram characteristics (i.e., fusion of the atrial electrogram component and the PV potential component). In addition, the mitral annulus was tagged. Ablation was performed during sinus rhythm. In patients with sustained AF at the beginning of the procedure, sinus rhythm was achieved with electrical cardioversion and stabilized, if necessary, with intravenous amiodarone or ajmalin. Kottkamp et al. J Am Coll Cardiol 2004;44:869–77 patients (30%) showed an arrhythmia recurrence (Fig. 1). The figure depicts the duration percentages ofof patients with monitoring recurrence that on[1]the Hindricks G, Influence of the Holter would have been detected with a Holter duration of 1 day, bucicchio C, e detection 2ofdays, arrhythmia catheter ablation diofrequency c 3 days etc., i.e. recurrences the percentages of after patientsAF who had an recurrence. Cir arrhythmiaImplications recurrence within thepatient first 24, 48, 72 h etc. of the for follow-up [2] Arya A, Piork recording up to the total duration of 7 days. The Figure shows implications o these data as percentages among the 64 patients who had a atrial fibrillati Recurrences during 7-day Holter recordings: 30% recurrence during the complete 7-day period. All Holter [3] Kottkamp H, T JH, et al. Tim durations up to 5 days would have detected significantly less episode numb patients with recurrence compared with the complete 7-day trigger elimina period: a 24-hour Holter would have detected 59%, a 48-hour Coll Cardiol 2 Holter 67% and a 72-hour Holter 80% of patients with [4] Coats AJ. Eth recurrence. In contrast, a 4-day Holter would have already 149–50. 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.10.004 Dagres. Int J Cardiol 2010; 139: 305-6 Role of Transtelephonic Electrocardiographic Monitoring in Detecting Short-Term Arrhythmia Recurrences after AF Ablation ECG+ 24h Holter 90d TTM Transtelephonic ECG is better than standard ECG and 24-h Holter recordings in evaluating AF relapses after RCA, thus decreasing the short-term success of ablation from 86% to 72%. Senatore G et al. J Am Coll Cardiol 2005;45:873– 6 Recurrence of AF & Mode Switching Events n=66 80 70 60 50 69% 40 30 No MSE MSE n=20 20 10 100% 19/21 (90%) pts <60 s 31% 0 Symptomatic Recurrence No Symptomatic Recurrence Verma A et al. JCE 2007; 18: 601-6 Time Course of Mode Switch Events (Patients with Asymptomatic Recurrence) • 19/21 (90%) pts the episodes fell in the blanking period (3 months post ablation) • 18 were when the pts were still taking AAD • Only 2 (3%) pts continued to have asymptomatic MSE after 3 months post-ablation Verma A et al. JCE 2007; 18: 601-6 (60%) to 16 (80%). What is the real AF burden after catheter ablation of atrial All symptomatic patients had at least one epis fibrillation? A prospective rhythm analysis in pacemaker patients mented in the Holter recordings during each fol with continuous atrial monitoring the patients, who reported to be asymptomatic, h rences. During the entire follow-up a significant burden has been shown (5.5 ! 10 – 13). Steven et al. Eur Heart J 2008; 29: 1037-42 What is the real AF burden after catheter ablation of atrial fibrillation? A prospective rhythm analysis in pacemaker patients with continuous atrial monitoring In patients with AF recurrences a significant decrease in AF burden was achieved. Steven et al. Eur Heart J 2008; 29: 1037-42 Keywords Atrial fibrillationisolation † Ablation † Pacemaker † atrial Atrial Holter recording (PVI) in patients with paroxysmal fibrillation (PAF, n ¼ 20) and additional substrate modification What is the real AF burden after catheter ablation of atrial fibrillation? A prospective rhythm analysis in pacemaker patients arrhythmia termination in patients with persistent or inducible AF after PVI as well as in patients with a history o lasting persistent AF (PersAF, n ¼ 17). The mean atrial Holter monitoring period was 7.4 + 3.3 months befo 13.5 + 4.2 months after ablation with an overall AF burden of 33.7% prior to ablation. During follow-up, AF b decreased from 17.3–0.65% (P ¼ 0.001) in PAF patients and from 57.4 to 13.9% (P ¼ 0.024) in patients with P Complete AF freedom was observed in 85%between (17 patients)60 of PAF (10 patients) patient andpatients 80%.1and In 59% patients withinpersis PersAF. The absence of symptoms correlated well with documented freedom of AF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .there . . . . . . . . . . .is . . . .growing . . . . . . . . . . . . . . . .evidence . . . . . . . . . . . . . . . . .that . . . . . . . . .additional . . . . . . . . . . . . . . . . . . .subs ...... Conclusion In the present study we could show, that freedom from AF can be achieved by catheter ablation in a high perc (PV) isolation has emerged as an effective therapy is necessary to achieve similar results as r of patients even with PersAF. Continuous atrial monitoring reveals AF ablation success rates comparable with 2,3 atrial fibrillation (PAF) assessed with success ranging patients. The electrophysiological by clinical rates evaluation. Symptomatic freedom of AF correlated well with the actual freedomendpoin of AF at l this highly symptomatic patient cohort. Introduction with continuous atrial monitoring Pulmonary vein for paroxysmal - - - - - - - - - -40- - - 42803 - - - - - - - - -4120, - - - - - - -Fax: - - - - - -þ49(0) - - - - - - - - - 40 - - - -42803 - - - - - - - - 4125, - - - - - - - Email: - - - - - - - - [email protected] -------------------------------------------------------------------------* Corresponding author. Tel:- - -þ49(0) Keywords Atrial fibrillation † Ablation † Pacemaker † Atrial Holter recording Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: journals.permissions@ Introduction Pulmonary vein (PV) isolation has emerged as an effective therapy for paroxysmal atrial fibrillation (PAF) with success rates ranging between 60 and there is growing is necessary to patients.2,3 The 80%.1 In patients with persistent AF (Pe evidence that additional substrate modifi achieve similar results as reported fo electrophysiological endpoints are ele * Corresponding author. Tel: þ49(0) 40 42803 4120, Fax: þ49(0) 40 42803 4125, Email: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: journals.permissions@oxfordjournals Steven et al. Eur Heart J 2008; 29: 1037-42 Paroxysmal AF burden before and after PV Isolation: an observational study through ILR Time to 1st recurrence of AF/AT after the 3-m blanking period: Figure 4. Figure Kaplan–Meier curve: timecurve: to firsttime recurrence AF/AT inofdays afterinthe 3-month blanking period (day 0). (A) First 4. Kaplan–Meier to first of recurrence AF/AT days after the 3-month blanking period (day procedure; 0). (A) Firs procedure. procedure. 7-9 rate of success more thanmore 1 procedure, at the endatofthe a endembolism, it must 7-9 notitbe considered as a “surro embolism, rate of with success with than 1 procedure, of a must not be considered 12-month12-month follow-up. The difference with our results in terms ablation “success.” Thus, in our study, AFB follow-up. The difference with our results in terms ablation “success.” Thus, inmonthly our study, m of the final rate of success may be due to the definition of was already present in some patients before the pr of the final rate of success may be due to the definition of was already present in some patients be success. They consider AFB values below <0.5% per month and in those a 90% reduction cu success. They consider AFB values below <0.5% per month andpatients in thosewith patients with a 90% in redu 7-9 after the blanking period as period a “responder” to ablation. was there some was assessment of monthlyofAFB Even 7-9 AFB after the blanking as a “responder” to ablation. some assessment mo Even thereAFB Group III with lack of efficacy had an especially low though this value is useful to define a patient at low risk of Group III with lack of efficacy had an esp though this value is useful to define a patient at low risk of 1° procedure 2° procedure Pedrote et al. J Cardiovasc Electrophysiol, 2013; 24: 1075-82 radiofrequency had 100% of positive predictive accurac and Joshi al.25 claimed that not havingan any epis Paroxysmal AF burdenLRAT; before andetafter PV Isolation: within the first 15 days predicted success in follow-up. I observational ILRoccurred very early an series,study the firstthrough ERAT episode median AFB for that month was 7.2 hours. Only in 2 Patients with symptomatic tients, and asymptomatic episodes ERATs occurred at the secondpre andand third month the procedure. It is possible that the ERATs in our pat post ablation: are not secondary to inflammatory or other type of even sociated with the ablation, but that, probably, they are ca by an incomplete PV isolation. Only 2 patients suffere first recurrence episode outside the interval of time tha consider the blanking period. It is important to highligh both patients had very low cumulative AFBpre, which m justify that the failure of PV isolation had not been reve at an earlier stage. It is well known that patients with AF have asymptom episodes.15,26 This also happens in patients who und ablation.13,20,23,24,27,28 In our study the number of epis Pedrote et al. J Cardiovasc Electrophysiol, 2013; 24: 1075-82 DISCERN AF study Asymptomatic AF/AFL/AT before and after ablation Prospective, multicenter study using ICM: AF recurrences after RCA: 12% totally asymptomatic Verma A et al. JAMA Intern Med. 2013;173:149-56 Discerning the incidence of symptomatic and asymptomatic AF Episodes before & after catheter ablation (DISCERN AF) Prospective, multicenter study using ICM: Verma A et al. JAMA Intern Med. 2013;173:149-156. symptoms (P = 0.059). Regarding the changes in quality of life ascertained by the SF-12 questionnaire, a significant improvement in mental and physical functioning and overall health-related quality of life from the baseline to the last follow-up visit was documented by the PCS (44.5 ± 8.5 vs up visit than at the baseline. There were no differ antiarrhythmic drug therapy use between symptom asymptomatic patients (6 months postablation: 80% P = 0.581; 12 months postablation: 82% vs 75%, P = or between those with and without AF recurrences. Rhythm-Symptom Correlation in Patients on Continuous Monitoring After Catheter Ablation of Atrial Fibrillation Only asymptomatc AF after 3-m follow up: 15% Figure 2. Relative burden of atrial fibrillation distribution during the follow-up by episode length. Tondo C et al. J Cardiovasc Electrophysiol 2014; 25: 154-60 symptoms (P = 0.059). Regarding the changes in quality of life ascertained by the SF-12 questionnaire, a significant improvement in mental and physical functioning and overall health-related quality of life from the baseline to the last follow-up visit was documented by the PCS (44.5 ± 8.5 vs up visit than at the baseline. There were no differences in antiarrhythmic drug therapy use between symptomatic and asymptomatic patients (6 months postablation: 80% vs 76%, P = 0.581; 12 months postablation: 82% vs 75%, P = 0.331) or between those with and without AF recurrences. Rhythm-Symptom Correlation in Patients on Continuous Monitoring After Catheter Ablation of Atrial Fibrillation Figure 2. Relative burden of atrial fibrillation distribution during the follow-up by episode length. Tondo C et al. J Cardiovasc Electrophysiol 2014; 25: 154-60 Rhythm-Symptom Correlation in Patients on Continuous Monitoring After Catheter Ablation of Atrial Fibrillation Symptom-Rhythm correlation based on pts symptoms report: 5/143: 3.5% Tondo C et al. J Cardiovasc Electrophysiol 2014; 25: 154-60 occurred beyond the TTM period and was detected by ILR. In one of these patients, based on no demonstration of AF by TTM, AADs had been discontinued. Of note, the 5 patients in the CM arm who refused TTM were still monitored by ILR and none of them experienced AF and/or other sustained arrhythmias, yet 3 of them remained on AADs for persisting palpitations. Figure 3. Percentage of patients in the implantable loop recorder (ILR) and conventional monitoring arms who reported symptoms suggestive of arrhythmia recurrence that were cross checked for accuracy via their ILR over the 12-month study period. Only in a minority did the symptoms correlate with true arrhythmia recurrences. Symptom Correlation with Arrhythmia Recurrence were all accurately detected by ILR. ILR also falsely detected asystole and ventricular tachycardia due to under or oversensing, respectively, of normal R waves (Table 2). In 11 patients where ILR frequently misclassified AF (>50% of all detections), following device reprogramming (signal amplitude threshold and AFMonitoring: sensitivity settings), Conventional overall accuracy of AF interpretation improved from 46% TwiceFordaily 1-min pulse rate the to 53.6% (P = 0.14). the 12-month study period, accuracy of ILRassessments for detecting AFby perthe episode was and 47.9% patient (681/1,421 episodes), but exclusive false AF detection (withthree 30-dayoccurred TTM periods (at out any true AF on adjudication) in only 5 patients (13%). discharge, 5 and 11 m Assessing Arrhythmia Burden After Catheter Ablation of Atrial Fibrillation Using an Implantable Loop Recorder: The ABACUSAF Study episodes also experienced true AF episodes, and these Over the 12-month study period, 13 patients randomized (65%) in the Single-center, prospective, study: ILR arm and 10 patients (56%) in the conventional arm reported arrhythmia symptoms (P = 0.741). In only 3 patients in the ILR arm and 4 patients in the CM arm did symptoms correlate with AF (total 7 of 23 patients reporting symptoms; 30%; Fig. 3). In the remaining 16 patients (70%), the arrhythmia symptoms correlated with isolated atrial or ventricular premature beats or normal sinus rhythm. Adjudication of ILR Tracings Over the first 6 months, ILR categorized 915 episodes as AF, of which 420 were adjudicated to be true AF (accuracy = 46.0%). The causes of ILR misclassification of AF included frequent premature atrial and ventricular contractions (36% of misclassified episodes) and over or undersensing of R waves (34% of misclassified episodes). Eighty-two of 495 misclassified episodes (17%) occurred in one patient, and 447 of 495 (90%) misclassified episodes occurred in 14 patients. Importantly, most patients (n = 13, 68%) with misclassified Impact of ILR onfollowing Patient Management ablation) In the overall cohort, ILR findings resulted in “actionable events” in 6 patients. In 5 patients these events were marked bradycardia and/or asystole as a result of which 2 patients received pacemakers and 3 patients had AADs withdrawn. In one patient, ILR detected asymptomatic self-terminating VT events resulting in AAD change. Of note, none of these events were detected by CM. Kapa S et al. J Cardiovasc Electrophysiol 2013; 24: 875-81 ported arrhythmia symptoms (P = 0.741). In only 3 patients in the ILR armBurden and 4 patients in the CM arm did symptoms of Assessing Arrhythmia After Catheter Ablation correlate with AF (total 7 of 23 patients reporting symptoms; Atrial Fibrillation Using an Implantable Loop Recorder: 30%; Fig. 3). In the remaining 16 patients (70%), the arrhythmia symptoms correlated with isolated atrial or ventricular The ABACUS Study premature beats or normal sinus rhythm. Symptom correlation with AF (accuracy checked via ILR): 30% Adjudication of ILR Tracings Over the first 6 months, ILR categorized 915 episodes as AF, of which 420 were adjudicated to be true AF (accuracy = 46.0%). The causes of ILR misclassification of AF included frequent premature atrial and ventricular contractions (36% of misclassified episodes) and over or undersensing of R waves (34% of misclassified episodes). Eighty-two of 495 misclassified episodes (17%) occurred in one patient, and 447 of 495 (90%) misclassified episodes occurred in 14 patients. Importantly, most patients (n = 13, 68%) with misclassified (>5 (sig ove to 5 acc (68 out (13 Imp I eve brad rece In o VT eve Kapa S et al. J Cardiovasc Electrophysiol 2013; 24: 875-81 Atrial Arrhythmia Burden on Long-Term Monitoring in Asymptomatic Pts Late After AF Ablation Asymtomatic atrial tachyarrhythmias >30 sec by pt at LTM done at 3.1± 1.3 yrs: 5% Winkle et al. Am J Cardiol 2012;110:840–4 Incidence of Asymptomatic AF (%) Discovered incidentally / ECG* 16 - 25 During AAD Therapy / TTEM^ 56 - 70 PM – ICD recipients / Device memory° 51 - 74 Post-AF Ablation / TTEM, 7-d Holter,”… 0 - 20 *Kerr CR et al. Eur Heart J 1996; 17 (suppl C): 48-51; Nieuwlaat R et al. Eur Heart J 2005; 26: 1422-34; Miyasake Y et al. Circulation 2006; 114: 119-25 ^Fetsch T et al. Eur Heart J 2005; 26: 1422-34; Patten M et al. Eur Heart J 2004; 25: 1395-404 °Israel CW et al J Am Coll Cardiol 2004; 43:47-5; Glotzer TV et al. Circulation 2003; 107: 1614-9 ; Capucci A et al. J Am Coll : Cardiol 2005; 26: 1913-20 “Oral H et al. J Cardiovasc Electrophysiol 2004; 15: 920-24; Hindricks G et al. Circulation 2005; 112: 307-13; Senatore, G. et al. J Am Coll Cardiol 2005;45:873-876; Neumann T et al. Europace 2006; 8: 495-8; Vasamreddy C et al. J Cardiovasc Electrophysiol 2006; 17: 134-9 ; Klemm HU et al. J Cardiovasc Electrophysiol 2006; 17: 146-50 ; Verma A et al. J Cardiovasc Electrophysiol 2007; 18: 1-6 ; Steven D et al. Eur Heart J 2008; 29:1037-42 Presence and duration of AF detected by continuous monitoring: crucial implications for the risk of TE Capucci et al. JACC 2005;46:1913–20 Botto et al. JCE 2009; 20: 241-8 The relationship between daily atrial tachyarrhytmias burden from implantable device diagnostics and stroke risk (The TRENDS study) TE rates for the overall study group (unadjusted): AT/AF burden is the maximum duration of AT/AF on any given day in the preceding 30 days Glotzer TV et al. Circ Arrhythm Electrophysiol 2009;2:474-80 Anticoagulation after AF ablation OAT at 12 months after ablation in relation to the CHADS2 score and the detection of recurrences during 6-month 7- day Holter: Dagres N et al. Thromb Haemost 2009; 102: 754–758 Thromboembolic Risk Factors According to CHADS2 Score in the Off- and On-OAT Groups 347 Themistoclakis et al. J Am Coll Cardiol 2010;55:735–43 Incidence of Embolic and Hemorrhagic Events Mean follow up: 28±13 and 24±15 months Off OAT group On OAT group 2692 663 Tromboembolic events, n (%) 2 (0.07) 3 (0.45) 0.06 Hemorrhagic events, n (%) 1 (0.04) 13 (2.0) <0.001 Patients, n (%) p Themistoclakis et al. J Am Coll Cardiol 2010;55:735–43 Key message Clinicians should be aware of the importance of long-term vigilance for AF recurrence, especially in patients with thromboembolic risk HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Minimal monitoring: • Patients should be seen in follow-up at a minimum of 3 months following the ablation procedure and then every 6 months for at least 2 years. • An event monitor should be obtained to screen for recurrent AF/flutter/tachycardia in patients who complain of palpitations during follow-up. • An AF/flutter/tachycardia episode is present if it is document by ECG and last at least 30 sec. • Patients being evaluated as part of a clinical trial or in whom warfarin may be discontinued should have some type of continuous ECG monitoring performed to screen for asymptomatic AF/flutter/tachycardia. • 24–hour Holter monitoring is an acceptable minimal monitoring strategy for patients enrolled in a clinical trial and is recommended at 3 to 6 months intervals for one to two years following ablation. Calkins H et al. Heart Rhythm 2012; 4: 816-61 2012 focused update of the ESC Guidelines for the management of atrial fibrillation Recommendation for screening of AF: Camm AJ et al. Eur Heart J 2012 ACC/AHA/HRS 2014 Guidelines Class I • AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired (Level of Evidence: A) • Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C) Class IIa • AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (Level of Evidence: A) • In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy (Level of Evidence: B) Class IIb • 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 (Level of Evidence: B) • AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C) Class III: Harm • AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C) Catheter Ablation of Asymptomatic Longstanding Persistent AF Exercise parameters: Mohanty S et al. J Cardiovasc Electrophysiol. 2014;25:1057-64 Catheter Ablation of Asymptomatic Longstanding Persistent AF Exercise parameters in successful vs failed procedures: Mohanty S et al. J Cardiovasc Electrophysiol. 2014;25:1057-64 Catheter Ablation of Asymptomatic Longstanding Persistent AF Baseline QoL score and the changes at 12-mo Follow-Up : Mohanty S et al. J Cardiovasc Electrophysiol. 2014;25:1057-64 Catheter Ablation of Asymptomatic Longstanding Persistent AF Arrhythmia Status and Heart Rate according to Symptom Status among patients with recurrence: Mohanty S et al. J Cardiovasc Electrophysiol. 2014;25:1057-64 EAST, SC meeting, 31.08.2014 An European Investigator-initiated, Prospective, Parallelgroup, Randomized, Open, Blinded Outcome Assessment Multi-centre Trial Conducted by AFNET and EHRA EAST setting and National PIs • • • • Approximately 3000 patients Enrolment in 11 European Countries (200 centres) Follow-up of all patients until end of trial (event-driven design) Expected mean follow-up time 3-4 years Belgium Czech Republic Denmark France Germany Great Britain Italy Netherlands Poland Spain Switzerland Prof. Hein Heidbuchel, Leuven Prof. Josef Kautzner, Prague Prof. Axel Brandes, Odense Prof. Etienne Aliot, Nancy Prof. Stephan Willems, Hamburg Prof. John Morgan, Southampton Prof. Michele Gulizia, Catania Prof. Sakis Themistoclakis, Venice Prof. Isabelle van Gelder, Groningen Prof. Lukasz Szumowski, Warsaw Prof. Lluis Mont, Barcelona Dr. Laurent Haegeli, Zurich Hypothesis Adequate and early comprehensive rhythm control therapy can prevent AF-related major complications (stroke, death, heart failure) compared to usual care Primary outcome: Composite of cardiovascular death, stroke, and heart failure or acute coronary syndrome measured as hospitalization Enrolment: Patients with recent-onset AF at risk for stroke or death