Download Catheter Ablation for AF: Patients, Procedures, Outcomes

Catheter Ablation for AF:
Patients, Procedures, Outcomes
John Sapp
Director Heart Rhythm, QEII Health Sciences Centre
Professor of Medicine, Dalhousie University
Atrial Fibrillation
Atrial Fibrillation is a
pain in the rear….
What makes it so
difficult?
Goals of Care?
Live longer
and / or
Live better
How can AF hurt your patients?
• Symptoms
• Stroke/Thromboembolism
• Tachycardia-induced cardiomyopathy
The indication for rhythm control is
inadequate symptom relief with rate control
How to Pick Rhythm Control
• The main goal is symptomatic control
Which one is better?
How To Choose Rate Vs Rhythm Control?
Liparus Weevil
Pissodes pini Weevil
The Devil you know?
Rate Control
Beta-blockers
++
Ca Channel Blockers
Digitalis
Rhythm Control
AF Ablation
Amiodarone, Sotalol,
Flecainide, Propafenone,
Dofetilide, Dronedarone
Young patients?
Athletes?
Resting Bradycardia?
?
How to rate control
• Beta-blockers
• Verapamil / Diltiazem
• Digoxin? Not dronedarone
• Sometimes pacemaker to permit drug therapy
• Rarely AVN ablation
How to Rate Control
• Target resting HR < 100
– Sometimes a treadmill test or loop recorder is
informative…
• Pill in the pocket rate control and
anticoagulation?
Rhythm Control
• Special cases for rhythm control:
– Heart failure?
– Young age
– Highly symptomatic
– Resting bradycardia / Athletes
Rhythm Control
• Sotalol
– Avoid in elderly women, use of diuretic, renal
dysfunction, hypokalemia, prolonged QT
– I start at 80-120 bid…not higher than 160 bid
• Flecainide
– Avoid in patients with ventricular scar
– I start at 50 mg bid, sometimes 100 bid, rarely
150bid
• Propafenone
– Avoid in patients with ventricular scar
– I start at 150 bid-tid, rarely 300 tid
Rhythm Control
• Sotalol: Monitor renal function over time,
check QTc interval intermittently, concern if
>470, reduce dose if >500
• Flecainide: Watch for side-effects—QRS
widening, other
• Propafenone: Watch for side-effects—
QRS widening, other
Rhythm Control
With Flecainide /
Propafenone,
I always use an
AV node
blocking agent
Catheter Ablation for AF
• Triggers
• Substrate
Who Should Have Ablation?
Risks
• 4.7% Complications
– 1.5% vascular
– 1% Perforation/Tamponade
– 1% Stroke/TIA
• Rarer Complications
– Pulmonary vein stenosis
– Phrenic nerve injury
– Atrio-esophageal fistula / Death
Redo Rates
• Seems to be changing…
– Was approximately 1 in 3
– Moving closer to 1 in 4-5….
Ablation Procedure
Ablation Techniques
• Radiofrequency Ablation
– Double trans-septal puncture
– Point-by-point ablation lesion delivery
encircling the pulmonary veins and electrically
isolating them
Andrade et al. CJC 2014; 30 S431-S441
Contact Force Sensing Catheters
TOCCASTAR
Reddy et al. Circulation Sep 2015
Recurrence at areas of low force < 10g
CryoAblation
• Liquid-Nitrogencooled balloon
• Advanced across
interatrial septum,
and inflated in
pulmonary venous
ostia
STOP-AF Trial: Cryoablation
Catheter Ablation for Persistent AF
• Patients with persistent AF have lower
success rates with catheter ablation than
paroxysmal patients…
Ablation for Persistent AF
Trials to come…
• Comparisons of Cryoablation against RF
ablation
• Comparison of cryoablation against
antiarrhythmic drug therapy as an early
intervention
• Comparison of AF Ablation versus drug
therapy with clinical endpoints
Longer Term Outcomes
• Most recurrences occur within the first
year after ablation
• Late recurrences:
– 87% 1 year, 81% at 2 years, 63% at 5 years…
– 85% at 3 years, 75% at 5 years
• Focus still remains on ablation to control
AF, not necessarily a cure…
AF Ablation in Heart Failure
LVEF
LVEDD
LV Fractional
Shortening
LVESD
Hsu, NEJM 2004
Freedom from AF after AF ablation
in patients with LV dysfunction
Hunter (N=26)
MacDonald (N=22)
De Potter (N=36)
Choi (N=15)
Efremids (N=13)
Lutomsky (N=18)
Khan (N=41)
Gentlesk (N=67)
Chen (N=94)
Hsu (N=58)
0%
10%
20%
30%
40%
50%
AF Free post-ablation
60%
70%
80%
90%
100%
RAFT-AF
•
Hypotheses
•
•
Key Inclusion Criteria:
•
•
•
•
Catheter ablation-based AF rhythm control as compared with rate
control in patients with HF of either impaired LV function (LVEF
≤ 45%) or preserved LV function (LVEF > 45%) will reduce allcause mortality or HF hospitalization
High burden AF – paroxysmal, persistent, long-term persistent
NYHA class II or III HF
Increased NT-proBNP/BNP
Intervention:
•
•
Rhythm control arm:
Rate control arm:
Catheter ablation ± AAD
Rest HR<80; 6MW HR <110
Conclusions
• Rhythm control is still directed at symptoms
• First-line therapy is still usually antiarrhythmic
drug therapy
• I think new technology is improving the
single-procedure success rate
• New trials will help us know best technology
for ablation, and role for ablation in heart
failure patients with AF
Conclusions
• AF Ablation works best for patients with:
– Paroxysmal atrial fibrillation
– Normal hearts
• Less appropriate for
– Very elderly
– Longstanding persistent AF
– Diseased atria, size > 50 mm…