Download After Catheter Ablation

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
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•
•
•
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