Download AF ablation

AF ablation is a waste of time
and money
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital
AF ablation is a waste of time
and money:
(you must be joking!)
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital
A recap of what we’ve
learnt this morning….
AF kills you (slowly)….
AF makes you miserable….
AF costs megabucks….
2.4% of the total NHS budget
Conventional treatments limited efficacy
Drugs only work in 1 in 3 patients
Not only are drugs potentially
ineffective but…..
• They often cause unacceptable side effects
• Discontinuation rates due to Adverse Effects:
• CTAF: 18% Amio, 11% Sotalol
• AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide
• They may increase mortality
• SPAF: esp. in heart failure
• AFFIRM: AAD associated with
mortality (p=0.0005)
Dronedarone isn’t the answer….
• Mild antiarrhythmic action
• AF recurrence at 1 year: 64% vs 75% for Placebo
• << Amiodarone (free from AF at 6 mo: 37% vs 58%)
• Increased mortality in Heart Failure (ANDROMEDA)
• Only approved by the NICE with reservations
….and neither is cardioversion
Finally, a cure is in sight!......
Culprit: triggers in pulmonary veins
Treatment: Pulmonary Vein Isolation
The procedure works…..
Current success rates 80%
in long standing persistent AF too..
N
Redo
AAD therapy
Results
Complications
Haissaguerre
JCE 2005
60
1/2
Stopped at
ablation
95% at 11
months
2 Tamponades
Oral
NEJM 2006
77
1/3
Amio 6/52 pre & 77% at 1
3/12 post
year
0
Postch
Circ 2008
88
1/2
Stopped at
ablation
81% at 20
months
2 Tamponades
1 TIA
Lo
JCE 2009
87
1/4
AAD for 2/12
post
79% at 21
months
1 Tamponade
It’s clearly better than drug therapy
AF ablation has evolved rapidly…
• Success rates have doubled
• Paroxysmal AF: 40-50% to 80-90%
• Persistent AF: 30-40% to 70-80%
• Procedure times have halved
• From 4-6 hours to 2-3 hours
• Complication rates have halved: 4% to 2%
Current technology has improved accuracy
The last thing we now need is a party
pooper!
Ablation
Drugs
80% chance of cure
One-stop solution
30% efficacy
Life long suffering
If you always do what you always did…you’ll
always get what you’ve always got
Yes, AF ablation costs money…
• 100,000 AF cases a year Median 1.5 procedures
• £4000 per ablation
• Total cost: half a billion pounds
But where would you rather spend
this money?
• ? Iraq War: £ 4.5 billion (Mar 2006)
• ? Olympics: £9.8 billion
• ? NHS IT project: £15 billion
• ? Bank Bailout £850 billion
Upfront costs outweighed by subsequent
savings…
• Costs of recurrent hospital admissions
• Electrical cardioversions
• Absences from work
• Costs of lifelong drug therapy
• Regular INR tests
• Decreased risk of the serious AF sequalae
• Stroke
• Heart Failure
Measures to make ablation more cost
effective
1. Careful patient selection: ablation not offered
• Very long standing Persistent AF (>3 years)
• Very large LA (>5.5 cm)
• Morbid Obesity (BMI >40)
• Age >80 years
• Significant co-morbidity
Measures to make ablation more cost
effective
2. Individualised ablation strategy:
Improve single procedure success rates
Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010
Finally...
What would you want?!