[PDF] - Case 70 yo with longstanding persistent AF. Paroxysmal AF diagnosed PDF Document

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Should We Ablate Asymptomatic AF in a Young Patient? Pro

Edward Paul Gerstenfeld, MD, FHRS

@Ed_Gerst

Professor of Medicine University of California, San Francisco 2.0

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70 yo with longstanding persistent AF. Paroxysmal AF diagnosed 1992 (44 yo) AF became persistent 2002. Asymptomatic. EF 67%. Rx ASA+diltiazem. 2018 developed DOE. Echo: EF 40-45%, severe RAE, LAE, mod MR/mild-mod TR Holter: Mean rate 82 bpm

Case

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Ø 4060 pts randomized to rate vs. rhythm control Ø Enrolled 1996-1999. Followed for mean 3.5 years

AFFIRM

Wyse et al. N Engl J Med. 2002 Dec 5;347(23):1825-33.

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AFFIRM – Predictors of Survival

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AF-Mediated Cardiomyopathy

10 20 30 40 50 60 70 80 LVEF Baseline LVEF Follow up

LVEF

44% 57%

Gentlesk et al. JCE 2004.

Ø LV EF increased by > 5% in 82% patients Ø LV EF normalized to ≥ 55% in 72% patients

Ø 67 pts with baseline EF ≤ 50% and “controlled” ventricular rate (<90 bpm)

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CASTLE AF

Primary endpoint: All-cause death or unplanned hospitalization due to worsening of heart failure

Marrouche et al. NEJM 2018 378(5):417.427.

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Overall Mortality

Marrouche et al. NEJM 2018 378(5):417.427. 25.0% 13.4%

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CHF Trials: Total Mortality

20 40 60 80 100

BHAT SAVE SCD-HeFT CASTLE AF

9.8 24.6 36.1 25 7.2 20.4 28.9 13.4

Control Intervention

Mortality (%)

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Prabhu …. Kistler. J Am Coll Cardiol 2017;70:1949–61

Ø68 pts with Per AF and LVEF≤45%. ØRandomized to Medical Rate Control vs. RFA ØCMR pre-ablation Ø1°endpoint LVEF by CMR Ø6-months post RFA

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CAMERA-MRI

Prabhu …. Kistler. J Am Coll Cardiol 2017;70:1949–61

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CABANA Trial Design

Ablation Therapy (1108)

Primary ablation:

PVI/WACA

Ancillary ablation:

Linear lesions
CFAE

Anticoagulation

Drug Therapy (1096)

Rate Control or
Rhythm Control
Anticoagulation

R 1:1

Key Inclusion Criteria

³65 years of age
<65 years of age with ³1

CVA/CV risk factor

Eligible for ablation and ≥2

rhythm or rate control drugs Enroll patients with new onset or under-treated paroxysmal, persistent, or longstanding persistent AF who warrant therapy No Exclusion Criteria Identified

Packer D. et al JAMA. 2019;321(13):1261-1274.

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Primary Endpoint (Death, Disabling Stroke, Serious Bleeding, or Cardiac Arrest) (ITT)

Packer D. et al JAMA. 2019;321(13):1261-1274.

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Estimates of All-Cause Mortality Risk (ITT)

Packer D. et al JAMA. 2019;321(13):1261-1274.

15 Ablated

1006 (90.8%)

repeat ablation 215 (19.4%)

Ablation Therapy 1108 Drug Therapy 1096 Drug Treated

1092 (99.6%)

rhythm control 953 (87.2%) rate control only 126 (11.5%)

Completed FU

1002 (90.4%) 48.9 mo

Completed FU

966 (88%) 48.2 mo

Not ablated

102 (9.2%)

Cross Over Ablated

301 (27.5%)

CABANA: Patient Randomization

Subjects 2204

Crossovers

* Withdrew <3 years

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Primary and Secondary Outcomes (Treatment Received)*

Ablation (N = 1307) Drug (N = 897) Hazard Ratio (95% CI) P- Value Primary Outcome 92 (7.0%) 98 (10.9%) 0.67 (0.50, 0.89) 0.006

Secondary Outcomes

All-cause mortality 58 (4.4%) 67 (7.5%) 0.60 (0.42, 0.86) 0.005 Death or CV hospitalization 538 (41.2%) 672 (74.9%) 0.83 (0.74, 0.94) 0.002

*pre-specified

Packer D. et al JAMA. 2019 Apr 2;321(13):1261-1274. Death, Disabling Stroke, Serious Bleeding, or Cardiac Arrest

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* Minority=Hispanic or Latino or non-white race

Primary Endpoint Sub-group Analysis All-Cause Mortality, Disabling Stroke, Serious Bleeding, Cardiac Arrest

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Adverse Events in CABANA

19 N=583 N=309 N=768 N=378

Leong-Sit et al. Circ Arrhythm Electrophysiol. 2010;3(5):452-7.

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J Am Coll Cardiol 2013;62:1990–7

Ø 180 patients with paroxysmal/persistent AF compared to 90 CTRLS Ø OAT: 0% CTRL vs. 88% AF Ø # SCI Persist > Parox > CTRL (41±28 vs. 33±23 vs. 12±27 p <0.01) Cognitive Function

Control Paroxysmal Persistent

Immediate Memory Visio-spatial abilities Language Attention Delayed Memory

* * * * *

*P<0.05

*

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1 year 3 years

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STAR AF II - Primary Outcome

p=0.15

Documented AF > 30 seconds after one procedure with or without AAD

59% 48% 44%

Verma et al N Engl J Med. 2015 May 7;372(19):1812-22

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STAR AF II AF Burden

Verma et al N Engl J Med. 2015 May 7;372(19):1812-22

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HRS/EHRA/ECAS 2017 Atrial Fibrillation Consensus Statement

∗∗ A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient because the potential benefits of the procedure for the patient without symptoms are uncertain

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Reasons to consider ablating

asymptomatic AF in a young patient:

Ø Randomized trial data only extend for 3-5 years. No data on 20-30+ years with AF. Ø Patients with AF who underwent ablation in CABANA had lower mortality over only 3.5 years. Ø For young AF patients, future risk of LA dilatation -> MR -> CHF. May be too late to address AF later. Early ablation better success. Ø Association of AF with dementia may be modifiable

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When is it appropriate to consider ablation for asymptomatic AF*?

Ø Young age (< ~60 years old) Ø Paroxysmal or recent persistent (<1 year) AF (echo surrogate mild-mod LAE) Ø Tachy or AF-mediated cardiomyopathy Ø Tachy/brady with conversion pauses otherwise requiring pacemaker Ø High risk occupation (pilot) with AF

*After a thorough discussion of the risks/benefits

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Thank you

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Cases

1) 50 yo male attorney Found to be in AF prior to wisdom teeth extraction Last ECG 2009 during insurance physical SR Meds: Lipitor, ASA 81mg Echo: Normal LV EF 65%, trace MR, moderate LAE 46ml/m2 Feels fine. Referred for AF ablation 2) 50 yo male engineer PAF since 2001. Progressed to persistent AF 2012 – recurred after CV x2. Meds: Mg++, Eliquis, MVI Echo: LV EF 40-45%; mild MR, moderate LAE 46ml/m2 Referred for AF ablation given declining EF

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Cases

1) 50 yo attorney Lost 20# Sleep study found moderate OSA – started CPAP CV – SR with marked first degree AV delay – AF recurred 2 after hours Loaded with dofetilide 500ug bid. CV to SR with Mobitz I AVB. Syncope. Dofetilide stopped. Back in persistent AF. 2) 50 yo engineer Loaded with dofetilide + CV Remained in SR for ~3 weeks and then AF recurred Wife felt he had more energy in SR Elected to undergo AF ablation.

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42 yo Commercial Airline Pilot

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AF Onset

R I P V C S R A LSP V

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First Recurrence AF – Post Blanking* (ITT)

*Using CABANA Monitors

Packer D. et al Heart Rhythm Late Breaking Clinical Trials 2018 36

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