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Recent Advances in Management of Atrial Fibrillation Ramesh Hariharan, MD, FHRS University of Texas Health Science Center at Houston Total Hospitalization Days Based on Presenting Arrhythmia 900 AF 800 Atrial Flutter Cardiac arrest 700 Conduction disease 600 Junctional 500 Premature beats Sick sinus syndrome 400 VF VT 300 Unspecified 200 100 0 Presenting Arrhythmia Camm AJ. Am J Cardiol. 1996;78(8A):3-11. Epidemiology of Atrial Fibrillation Most common arrhythmia in Clinical Practice > 5 million patients worldwide 400,000 new cases diagnosed annually 2.5 Million estimated patients in the United States Major cause of stroke 200,000 annually worldwide/80,000 in the U.S. 25-30% of all strokes in the U.S. U.S. cost to treat = $3.6 billion annually Drug therapy + hospital admissions World map showing the age-adjusted prevalence rates (per 100 000 population) of atrial fibrillation in the 21 Global Burden of Disease regions, 2010. Sumeet S. Chugh et al. Circulation. 2014;129:837-847 Copyright © American Heart Association, Inc. All rights reserved. 2010 Global Burden of Diseases Study Worldwide age adjusted prevalence of atrial fibrillation 596/100K men have atrial fibrillation. 373/100K women have atrial fibrillation. ~33 million people 1-4% population in USA, Europe and Australia In population > 80 years age~13% In the USA: 3-5 million patients with Afib. Estimated >8 million by 2050 In Europe: ~8 million patients with Afib. Estimated > 18.8 million by 2060 In areas with growing populations China:3.9 million patients with Afib > 60 yr olds. That population estimated to increase to 450 million by 2050. Estimated Afib population 9 million India:? . At risk population estimated to grow from 96 million to > 330 million. Africa: ?. At risk population estimated to grow from 53 million to > 220 million. Ethnicity and Atrial Fibrillation • Kaiser Permanente data (2008) White: 8% Black: 3.8 Hispanic: 3.6% Asian: 3.9% • West Birmingham AF project (1998) Prevalence of AF in general population > 50 yrs old~2.4% Prevalence of AF in Asian population> 50 yrs old 0.6%. • ASSERT data (JCE 2013) • Analysis of Afib in patients who received dual chamber pacemakers AF in pts of European ancestry> AF in pts of African ancestry> AF in pts of Asian ancestry Disability-adjusted life-years (DALYs) related to atrial fibrillation. Sumeet S. Chugh et al. Circulation. 2014;129:837-847 Copyright © American Heart Association, Inc. All rights reserved. Atrial Fibrillation: Cardiac Causes Hypertensive heart disease Ischemic heart disease Valvular heart disease Rheumatic: mitral stenosis Non-rheumatic: aortic stenosis, mitral regurgitation Pericarditis Cardiac tumors: atrial myxoma Sick sinus syndrome Cardiomyopathy Hypertrophic Idiopathic dilated (? cause vs. effect) Post-coronary bypass surgery Atrial Fibrillation: Non-Cardiac Causes Pulmonary COPD Pneumonia Pulmonary embolism Sleep Apnea Metabolic Thyroid disease: hyperthyroidism Pheochromocytoma Electrolyte disorders Toxic: alcohol (‘holiday heart’ syndrome) Risk factors for Afib around the world Why Do we need to Treat AF? STROKE TACHYCARDIA palpitations, cardiomyopathy, CHF LOSS OF ATRIAL KICK Thromboembolism Prevention Ventricular Rate Control Rhythm Control Dyspnea, fatigue, CHF (Benjamin et al. From Framingham Study. Circulation 1998;98:946-952.) The Pillars of Afib Treatment in 2016 Anticoagulation Stroke Prevention Rate Control Rhythm Control Risk Factor Modification Effect of rosuvastatin on incident atrial fibrillation according to various baseline characteristics. Jessica M. Peña et al. Eur Heart J 2012;33:531-537 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2011. For permissions please email: [email protected] IL-6 and CRP and Atrial Fibrillation • Sub-Analysis of the RE-LY population • IL-6 elevation independently associated with Higher stroke risk Higher systemic embolism risk Higher bleeding Higher CV mortality Higher composite thromboembolic outcome • CRP elevation independently associated with Higher MI Higher CV mortality Higher composite thromboembolic outcome Aulin, J et al; Am Heart J 2015 Dec;170:1151-60 Obesity and Atrial Fibrillation ARIC study: Huxley at al. Circ 2011-Obesity accounts for 17.9%. Close second to HTN as the etiology of atrial fibrillation. 3.5-5.3% higher risk of atrial fib per unit increase in BMI. ORBIT-AF: Pandey A et al. JACC EP 2016 >20% prevalence of sleep apnea LEGACY Trial Lau et al Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort-A Long-Term Follow-Up Study (LEGACY) Pathak RK et al; (J Am Coll Cardiol 2015 May;65:2159–69 1405 patients Dietitian counselled 3% wt loss Meal replacement sachets for 2 meals to achieve 10% wt loss Target BMI <25 Exercise 20min x 3/ week -200 min/wk Weight loss groups Group I> 10% wt loss Group II>3%<9% wt loss Group III<3% wt loss Weight Fluctuation Groups >5% >2%<5% <2% Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort-A Long-Term Follow-Up Study (LEGACY) Pathak RK et al; (J Am Coll Cardiol 2015 May;65:2159–69 Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort-A Long-Term Follow-Up Study (LEGACY) Pathak RK et al; (J Am Coll Cardiol 2015 May;65:2159–69 Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort-A Long-Term Follow-Up Study (LEGACY) Pathak RK et al; (J Am Coll Cardiol 2015 May;65:2159–69 Exercise Training and Atrial Fibrillation: Further Evidence for the Importance of Lifestyle Change. Elliott, Adrian; Mahajan, Rajiv; MD, PhD; Pathak, Rajeev; MBBS, PhD; Lau, Dennis; MBBS, PhD; Sanders, Prashanthan; MBBS, PhD Circulation. 133(5):457-459, February 2, 2016. Figure. Overview of existing knowledge regarding exercise training and atrial fibrillation. AF indicates atrial fibrillation; BP, blood pressure; and HR, heart rate. © 2016 by the American College of Cardiology Foundation and the American Heart Association, Inc. . Published by American Heart Association. 2 Figure 2. Adjusted risk of developing atrial fibrillation according to age and fitness categories. Charles Faselis, Peter Kokkinos, Apostolos Tsimploulis, Andreas Pittaras, Jonathan Myers, Carl J. Lavie, Fiorina Kyritsi, Dragan Lovic, Pamela Karasik, Hans Moore Mayo Clinic Proceedings, Volume 91, Issue 5, 2016, 558–566 http://dx.doi.org/10.1016/j.mayocp.2016.03.002 Percentage (95% CI) of participants with lone AF (cases) according to accumulated highintensity physical exercise (local likelihood regression). >1hr/week for > 20 years Naiara Calvo et al. Europace 2016;18:57-63 © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology Pill-in-the-Pocket Approach Rate control during Pill-in-the Pocket Diltiazem-Metabolized through CYP2D6 Carvedilol-Metabolized through CYP2D6 Use of Propafenone vs Flecainide Doctor, your patient is going in and out of VT all the time.” Afl 1:1 Management strategies 1. Anticoagulation strategies 2. Antiarrhythmic drugs 3. Ablation strategies 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. R2CHADS2 and ATRIA ATRIA-AnTicoagulation and Risk factors In Atrial fibrillation validated in the ROCKET-AF trial 14K+ patients: Female CHF HTN DM Instead of vascular disease, weighted creatinine clearance < 45 ml/min and proteinuria Added age as a function of prev stroke/TIA adding 0-9 points. Total score 15 points Renal Dysfunction as a Predictor of Stroke and Systemic Embolism in Patients With Nonvalvular Atrial Fibrillation: Validation of the R2CHADS2 Index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) Study Cohorts. Piccini, Jonathan; MD, MHS; Stevens, Susanna; Chang, YuChiao; Singer, Daniel; Lokhnygina, Yuliya; Go, Alan; Patel, Manesh; Mahaffey, Kenneth; Halperin, Jonathan; Breithardt, Gunter; Hankey, Graeme; Hacke, Werner; MD, PhD; Becker, Richard; Nessel, Christopher; Fox, Keith; MB, ChB; Califf, Robert Circulation. 127(2):224-232, January 15, 2013. DOI: 10.1161/CIRCULATIONAHA.112.107128 Figure 1 . Adjusted cumulative incidence of stroke or non-central nervous system embolism according to prior stroke or transient ischemic attack and baseline creatinine clearance after adjustment for covariates. The vertical axis is the cumulative incidence by percent. The horizontal axis represents the follow-up in days. CrCl indicates creatinine clearance (in mL/min). © 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc. . Published by American Heart Association. 2 Renal Dysfunction as a Predictor of Stroke and Systemic Embolism in Patients With Nonvalvular Atrial Fibrillation: Validation of the R2CHADS2 Index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) Study Cohorts. Piccini, Jonathan; MD, MHS; Stevens, Susanna; Chang, YuChiao; Singer, Daniel; Lokhnygina, Yuliya; Go, Alan; Patel, Manesh; Mahaffey, Kenneth; Halperin, Jonathan; Breithardt, Gunter; Hankey, Graeme; Hacke, Werner; MD, PhD; Becker, Richard; Nessel, Christopher; Fox, Keith; MB, ChB; Califf, Robert Circulation. 127(2):224-232, January 15, 2013. DOI: 10.1161/CIRCULATIONAHA.112.107128 Figure 2 . Cumulative incidence of stroke or non-central nervous system systemic embolism according to R2CHADS2 scores (R2CHADS2 indicates CHADS2 [risk stratification system that awards 1 point each for the presence of congestive heart failure, hypertension, age >=75 years, and diabetes and 2 points for prior stroke or transient ischemic attack] + 2 points if creatinine clearance <60 mL/min). The vertical axis is the cumulative incidence by percent. The horizontal axis represents the follow-up in days after randomization. © 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc. . Published by American Heart Association. 2 CHADS2 vs CHADSVASc2 Gage BF et al; JAMA, Vol. 285, 2001, 2864-2870 Lip GY et al; Chest, Vol. 137, 2010, 263-272 More Women on AC Ethnicity and anticoagulation Despite lower prevalence and younger age, Asian patients in RE-LY had worse stroke outcomes. Prescribing habits, patient compliance and genetic factors CYP2C9, VKORC1 etc In the GARFIELD registry (2013), 40.7% pts with CHADSVASC>2 were NOT receiving anticoagulants. In the worldwide RE-LY registry only 34% of patients with CHADS >2 were receiving anticoagulation Kaiser Permanente data: Risk of hemorrhage in Asians 2X> hispanics> blacks> whites Country Distribution of Mean Time in Therapeutic Range in the RE-LY Trial 5791 Patients on warfarin A large proportion of patients were outside the therapeutic range Wallentin, et al., Efficacy and safety of Dabigatran compared with Warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial; The Lancet, 2010: 376; 975 - 983 Do the appropriate patients receive stroke prophylaxis? Approximately 50% loss of compliance at 3 years1 100 Reasons: Dementia and inability to cope with the dose adjustments and monitoring required of warfarin2. Patients (%) 80 60 CHADS2 = 0 CHADS2 = 1 CHADS2 = 2 CHADS2 = 3 CHADS2 = 4 CHADS2 = 5 CHADS2 = 6 40 20 0 0 1 2 3 4 Time (years after starting treatment) 1. Gallagher AM, et al., Initiation and persistence of warfarin or aspirin in patients with chronic AF in general practice J Thromb Haemost 2008; 6: 1500–6. 2. Khoo, Lip Initiation and persistence of warfarin or aspirin as thromboprophylaxis in chronic AF - J Thromb Haemost 2008; 6: 1622 5 6 Newer Anticoagulants Newer AC in trials Advances in Anticoagulant Therapy Coumadin-greater use of home monitoring Target INR in trials 55-64% of the time. Dabigatran –PRADAXA 150/110/75 mg BID RELY trial Rivaroxaban-XARELTO 20/15/10 mg QD ROCKET AF Apixiban-ELIQUIS 5mg PO BID ARISTOTLE Edoxaban-LIXIANA 60/30 mg QD ENGAGE AF-TIMI48 Betrixiban • • • 10-12% mortality reduction 21% reduction in stroke/systemic embolism 31% reduction in major bleeding episodes When compared with Warfarin Bleeding Risk Calculator Reversal of Bleeding associated with NOAC Idarucizumab • • • • • • • Humanized Monoclonal antibody that binds free and thrombin dabigatran Idarucizumab-Dabigatran complex cleared by the kidney 350X affinity for Dabigatran than Thrombin. Dose dependent reversal of anticoagulant effect Onset of action in 5 minutes. No procoagulant effect in the absence of Dabigatran REVERSE-AD: Phase III, open label, single arm trial. Trial ongoing till Dec 2017 • Interim results on 90 patients published for expedited FDA review. • Normalized Thrombin Time and Ecarin clotting time in minutes • Normal intraoperative hemostatis in 94.3% of pts undergoing emergency surgery Pollack CV et al; Pollack CV et al; Reversal of Bleeding associated with NOAC Andexanet alpha Recombinant modified form of FXa Bolus and infusion of medication for 1 hour More effective against Apixaban than over Rivaroxaban ANNEXA-A: specific trial assessing efficacy in older patients against Apixaban ANNEXA-R: specific trial assessing efficacy in older patients against Rivaroxaban Reversal of Bleeding associated with NOAC Aripazine • Also known as Ciraparantag • Synthetic small molecule cation • Still in Phase I and II trials. • Can bind to Factor Xa inhibitor Dabigatran Heparins LMWH Fondaparinux Suggested strategy for management of TSOAC-associated bleeding. Deborah M. Siegal et al. Blood 2014;123:1152-1158 ©2014 by American Society of Hematology Complication rates related to centre volume of ablation procedure. Jian Chen et al. Europace 2015;17:1727-1732 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: [email protected]. Figure 3. Example of atrial diastolic dysfunction with associated systolic dysfunction. A: LA pressure tracing recorded before any LA ablation. B: LA pressure tracing recorded at the time of initial transeptal access during a repeat ablation procedure. Note th... Douglas N. Gibson, Luigi Di Biase, Prasant Mohanty, Jigar D. Patel, Rong Bai, Javier Sanchez, J. David Burkhardt, J. Thomas Heywood, Allen D. Johnson, David S. Rubenson, Rodney Horton, G. Joseph Gallinghouse, Salwa Beheiry, Guy P. Curtis, David N. Cohen, Mark Y. Lee, Michael R. Smith, Devi Gopinath, William R. Lewis, Andrea Natale http://dx.doi.org/10.1016/j.hrthm.2011.02.026 Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors Heart Rhythm, Volume 8, Issue 9, 2011, 1364–1371 Comparison of Antiarrhythmic Drug Therapy and Radiofrequency Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation: A Randomized Controlled Trial JAMA. 2010;303(4):333-340. doi:10.1001/jama.2009.2029 In case of Bleeding with Newer AC Triple Oral Antithrombotic Therapy Oral anticoagulant + Dual Antiplatelet Rx Following ACS with use of stent-Class IIb Considerable heterogeneity. SCAI survey-if bare metal stents are used, 87% preferred TOAT for 1 month foll by ASA+Warfarin SCAI survey-if DES-47% preferred TOAT for 6 months Triple Oral Antithrombotic Therapy • WOEST trial: What is the Optimal antiplatelet and anticoagulant strategy in pts with Atrial fibrillation And coronary stenting? • Bleeding exceeds thromboembolic risk when HAS-BLED score ≥ 4 • If CHADS-VASC ≥ 2 then OAC is favorable even if HAS-BLED is 3 • Prefer Radial artery approach for intervention. • Along the lines of HORIZONS-AMI-Bivalirudin preferable to UFHeparin+GPIIb-IIIa inhibitor • Avoid GPIIb-IIIa inhibitor • Use 81 mg ASA when possible • Avoid concomitant NSAID use. • Warfarin preferable. Keep INR 2.0-2.5 • NOAC • Consider Dabigatran. Note the 110 mg dose of Dabigatran had favorable bleeding profile even when pts were on single antiplatelet agent OR • Apixaban 5 mg PO BID. Dewilde WJ et al. Gallego P et al. Circ Arrhythm Electrophysiol. 2012;5:312-318 Ruiz-Nodar JM et al. Circ Cardiovasc Interv. 2012;5:459-466 Triple Oral Antithrombotic Therapy Treatment strategies Rate or Rhythm control…… its never that obvious Figure 1. Cumulative cardiac mortality in the rhythm-control and rate-control groups. Jonathan S. Steinberg et al. Circulation. 2004;109:19731980 AFFIRM STUDY Copyright © American Heart Association, Inc. All rights reserved. Figure 2. Cumulative noncardiovascular mortality in the rhythm-control and rate-control groups. Jonathan S. Steinberg et al. Circulation. 2004;109:19731980 AFFIRM STUDY Copyright © American Heart Association, Inc. All rights reserved. •Sinus rhythm was associated with a 47% reduction in the risk of death whereas use of antiarrhythmic drug therapy was associated with a 49% increase in mortality The toxicity of AADs counterbalances the benefits of SR Rate control - How slow do you go? AFFIRM: HR <80bpm at rest and <110bpm with six minute hallway walk. Digoxin (more for resting HR >100) Beta blockade/Calcium channel blockade (more useful in ambulatory HR>120) 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Intracardiac Electrograms: During RF Ablation First descriptions of Tachycardia Mediated Cardiomyopathy Gossage AM, Braxton Hicks JA. On Auricular Fibrillation. Q J Med July 1913 From: Chapter 224. Basic Biology of the Cardiovascular System Harrison's Principles of Internal Medicine, 18e, 2012 Bowditch Phenomenon: Tachycardia increases Contractility Treppe Effect β-adrenergic agonist interacts with the β receptor, a series of G protein– mediated changes leads to activation of adenylyl cyclase and the formation of cyclic adenosine monophosphate (cAMP). The latter acts via protein kinase A to stimulate metabolism (left) and phosphorylate the Ca2+ channel protein (right). The result is an enhanced opening probability of the Ca2+ channel, thereby increasing the inward movement of Ca2+ ions through the sarcolemma (SL) of the T tubule. Ca2+ ions release more calcium from the sarcoplasmic reticulum (SR) interacting through Ryanodine receptor (RyR2) to increase cytosolic Ca2+ and activate troponin C. Ca2+ ions also increase the rate of breakdown of adenosine triphosphate (ATP) to adenosine diphosphate (ADP) and inorganic phosphate (Pi). Legend: Date of download: 9/7/2014 Enhanced myosin ATPase activity explains the increased rate of contraction, Enhanced activation of troponin C explaining increased peak force development. An increased rate of relaxation is explained by the fact that cAMP also activates the protein phospholamban, situated on the membrane of the SR, that controls the rate of uptake of calcium into the SR. The latter effect explains enhanced relaxation (lusitropic effect). P, phosphorylation; PL, phospholamban; TnI, troponin I. (Modified from LH Opie, Heart Physiology, reprinted with permission. Copyright LH Opie, 2004.) Copyright © 2014 McGraw-Hill Education. All rights reserved. Tachycardia Mediated Cardiomyopathy 1. Phosphorylation of Protein Kinase A 2. Sets the stage for Ca2+ induced Ca2+ release 3. Calstabin2, a peptidyl-prolyl isomerase is a regulatory component of the RyR2 complex 4. Calstabin2 binding to RyR2 is regulated by PKA phosphorylation of Ser2809 in RyR2 5. Phosphorylation of RyR2 decreases binding affinity for calstabin2 and increases RyR2 sensitivity to Ca2+-dependent activation 1. 2. 3. 4. 5. RyR2 becomes chronically PKA hyperphosphorylated Depletion of Calstabin from the RyR2 complex Results in a diastolic outward Ca2+ leak. Depleted intracellular Ca2+ levels Reduced Inotropy Legend: From: Chapter 224. Basic Biology of the Cardiovascular System Harrison's Principles of Internal Medicine, 18e, 2012 Date of download: 9/7/2014 Copyright © 2014 McGraw-Hill Education. All rights reserved. Biv pacing, post ECG Pacing at Site of Late Activation Biventricular (Bi-V) pacing at a site of late electrical activation has been shown to improve CRT outcomes 1,2,3 BiV pacing at site of late electrical activation offers a way to optimize the LV pacing site3 Quartet™ LV Lead 1.Gold MR et al. The relationship between ventricular electrical delay and left ventricular remodeling with cardiac resynchronization therapy. Euro Heart J 2011; 32, 2516-2524 2.Polasek R et al. Local electrogram delay recorded from left ventricular lead at implant predicts response to cardiac resynchronizaiton therapy; retrospective study with 1 year follow up. BMC Cardiovascular Disorders 2012; 12:34 3.Pappone C, et al. Left ventricular pacing from a site of late electrical activation improves acute hemodynamic response to cardiac resynchronization therapy. (Abstract) APHRS 2012 Tachycardia Mediated Cardiomyopathy Questions 1. Rate Control? 2. Pace and Ablate AVN? 3. Biventricular pace and ablate AVN? 4. Ablate the arrhythmia? EKG during DUAL Chamber Pacing from RA and HIS bundle Conversion of atrial flutter to NSR during RF ablation Amiodarone or Referral for ablation Who is Candidate for AF Ablation? Patients with symptomatic recurrent atrial fibrillation refractory to at least 1 antiarrhythmic medication Atrial Fibrillation No (or minimal) heart disease Hypertension Flecainide Propafenone Sotalol Substantial LVH Amiodarone Dofetilide Catheter ablation No Yes Flecainide Propafenone Sotalol Amiodarone Amiodarone Dofetilide Catheter ablation Coronary artery disease Heart failure Dofetilide Sotalol Amiodarone Dofetilide Amiodarone Catheter ablation Catheter ablation Catheter ablation Fuster V et al. J Am Coll Cardiol. 2006;48:e149-246. Atrial Fibrillation Ablation “Your EKG showed atrial fibrillation, but we fixed it with………. Photoshop” The LA Myocardium Invasion CONTACT FORCE 85 CONTACT FORCE SENSING • Fluoroless Ablation-FIRST EP group in Houston! Procedure Fluoroscopy Time Range Atrial Flutter Ablation 10 - 30 minutes SVT Ablation 8 - 26 minutes Atrial Fibrillation Ablation 30 mins - 1 hour Persistent Atrial Fibrillation ablation Chest X-Ray Equivalents NOW 0 -1 16 - 49 chest x-rays 0 -1 12 - 39 chest x-rays 50 to 106 chest x-rays 1-5 36 seconds of Xray time Afib Termination with ablation •Better QoL •Decreased Hospitalization (54% vs. 9%) RF CATHETER ABLATION IS SAFE AND EFFECTIVE IN OCTOGENARIANS Up to 10% of people over 80 have AF Up to 25% of strokes in this group are due to AF This study compared safety and efficacy of RF ablation in two groups; greater and less than 80 years Success rates and complications were similar between the two groups Santangeli et al. Catheter Ablation of Atrial Fibrillation in Octogenarians: Safety and Outcomes. J Cardiovasc Electrophysiol, Vol. 23, pp. 687-693, July 2012 AF ablation in Persistent AF population AF ablation in Persistent AF population AF ablation in Persistent AF population TOCCATA STUDY 98 Reddy et al, Heart Rhythm, Volume 9, Issue 11, November 2012, Pages 1789-1795 ToccaStar trial: Force Sensing Ablation Catheters: Have our Hopes Been Realized” • • • • TactiCath Contact Force Ablation Catheter for the treatment of paroxysmal Afib 300 patients Strict follow up with monitoring for any arrhythmia longer than 30 seconds Noninferior to Carto Thermacool Navistar catheter 99 Mansour et al, AF Summit, HRS 2014 How to achieve durable pulmonary vein isolation: Use the force Beware of the Dark Side! A Jedi’s strength flows from the Force. Use it. > 20gms! 100 Bilchick KC et al, Heart Rhythm, Volume 9, Issue 11, November 2012, Pages 1796-1797 ROTOR Mapping. OASIS trial-evaluation of FIRM Mapping in long standing persistent AFIb HRS Late breaker May 2016 12 month freedom from A fib Group I FIRM map alone 4% Group II PVAI + FIRM 52.4% Group III PV Isolation + 76% posterior wall +/non PV trigger ablation GP ablation AFACT trial HRS Late breaking trial May 2016 Epicardial thoracoscopic ablation of GP in long standing persistent Afib Group I: PVI alone No clinical difference in AFib. Group II: PVI + GP ablation • • • • increased bleeding sinus node dysfunction higher need for pacing higher need for sternotomy 4 deaths. Left Atrial Appendage is the culprit Left atrial appendage: Occluders Positioning the transseptal sheath in AP projection Left atrial appendage by TEE prior to and after suture delivery LA appendage occluders The Watchman Device The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial. • Need warfarin coverage until endothelialization of device occurs. • Typically can stop warfarin in about 45 days. Event rate 3/100 patient years in the Watchman Arm Event rate 4.9/100 patient years in the Warfarin Arm http://www.youtube.com/watch?v=ZFWMB42Y0KE Holmes DR et al, Lancet 2009 Aug 15;374(9689):534-42 Fountain RB et al, Am Heart J 2006;151(5):956–61. The AMPLATZER device • Currently part of research trial that we are enrolling in. • Can be randomized to anticoagulation arm. • Warfarin anticoagulation not necessary. • Clopidogrel and aspirin for 1-3 months, followed by aspirin alone for ≥5 months for platelet inhibition.