Download Recent Advances in Management of Atrial Fibrillation

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)
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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
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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%.

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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
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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
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•
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•
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•
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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
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
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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.