Disclosure Ablation and Devices for Atrial Fibrillation - - PDF document

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Disclosure Ablation and Devices for Atrial Fibrillation - - PDF document

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10/10/19 Disclosure Ablation and Devices for Atrial Fibrillation SentreHeart/Atricure, Inc Should all Patients have Ablation? 1 2 AF PAROXYSMAL PERSISTENT AF LONG STANDING AF . PERMANENT AF . Diagnosis AF Risk Factor Modification 33.5

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Ablation and Devices for Atrial Fibrillation – Should all Patients have Ablation?

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Disclosure

SentreHeart/Atricure, Inc

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INTRODUCTION GROWTH MATURITY DECLINE

1 2 3 4

AF PAROXYSMAL Diagnosis PERSISTENT AF LONG STANDING AF. PERMANENT AF. 33.5 Million WW High BP CHD Rheumatic HD Hyperthyroidism Obesity/Diabetes Sleep Apnea HX of AF Behaviors Increase Risk Alcohol and Caffeine High Stress

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AF Risk Factor Modification

  • HTN
  • DM
  • Obesity
  • Sleep Apnea
  • Alcohol
  • Excercise

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Hypertension Diabetes Sleep Apnea Obesity (BMI ≥30 kg/m2)

1994 2000 2010

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

Curtesy of Suneet Mittal

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Obesity and AF Progression

Tsang et al. EHJ 2008

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Restore Maintain Protect

Standard “Historical” Treatment for AF

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A cardiac disease that kills by producing emboli

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The Real Debate

  • Anti-arrhythmic drugs versus catheter ablation

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Anti-arrhythmic Drugs

  • Amiodarone

– Toxicities: Lung, Thyroid, Cataracts, Skin, Neurological

  • Class Ic (encainide, flecainide, propafenone)

– Increase mortality in patients with ischemic heart disease

  • Dofetilide/Sotalol

– Torsade

Echt DS et al. N Engl J Med 1991;324:781-788.

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Potential Sites of Triggers

** ** ** ** *

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10/10/19 4 Cornerstone of AF Ablation is PVI

Brooks AG, et al. Outcomes of long standing persistent AF: A systematic review. Heart Rhythm. 2010; 7:835-46

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Additive Catheter Ablation Strategies

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Cox Maze III Cut and sew Maze

“Gold Standard” for Non- Pharmacological Treatment of AF

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Prasad SM. J Thorac Cardiovasc Surg. 2003;126:1822-28.

Benefit of LAA Closure

“Cut and sew” Cox-Maze Cox J., et al. J Thorac Cardiovasc Surg 1999;118:833-840

AF, Hx TE, No OAC AF, No TE, No OAC AF, Hx TE, OAC AF, No TE, OAC AF, No Risk, No TE, No OAC Post maze, No OAC, No LAA

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B

UCSF Sub-X MAZE (Epicardial)

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LAA

A B C D E F

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  • Multi-center, prospective randomized trial
  • Comparing LAA ligation and PVI versus PVI in

patients with persistent and longstanding persistent AF

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Case Presentation

  • 55 yo gentleman

– Hx of longstanding AF – CHADs score 1 – Refractory to medical therapy – Failed 2 previous PV

  • How do you treat this patient?

– Repeat PVI – AVJ ablation and pacemaker – Surgical MAZE – Rate control and OAC therapy; and live with your symptoms

  • LAA ligation, PVI, LAPWI, CTI 5/2011 (Percutaneous “MAZE”)

– Remains in sinus rhythm

IV C MV T V SVC

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CABANA trial Crystal AF trial

Land Mark Trials

Relieve Symptoms Improve cardiovascular outcomes

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CABANA Trial

Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial 22

  • Primary end point:

– Composite of death, disabling stroke, serious bleeding, or cardiac arrest.

  • Secondary endpoints:

– all-cause mortality – total mortality or cardiovascular hospitalization – and AF recurrence

Cabana Trial

23 Kaplan-Meier Estimates of the Primary End Point

(composite of death, disabling stroke, serious bleeding, or cardiac arrest)

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Recurrent Atrial Fibrillation After Blanking by Intention-to-Treat Analysis 25 The composite secondary end point of death from any cause or CV hospitalization 26

Case

  • In 2002, 61 year old man with history of

asymptomatic AF

– Treated with rate control and warfarin

(AFFIRM) Investigators. N Engl J Med 2002;347:1825-1833.

AFIRM Trial RACE-2 Trial

Van Gelder IC et al. N Engl J Med 2010;362:1363-1373.

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Case

  • In 2017, Presents to clinic for second opinion

– Still being treated with rate control and warfarin – Normal LVEF in 2002, now LVEF is 35%

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The CASTLE-AF Trial

Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation

  • Symptomatic PAF or Persistent

AF

  • Failure or intolerance to AAD or

unwillingness to take AAD

  • LVEF < 35%
  • NYHA class > II

Inclusion Criteria Primary Endpoint

  • All-cause mortality
  • Worsening heart failure

admissions

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Summary

  • Drugs

– Toxicities – don’t work long term – can lead to death

  • Catheter ablation

– Decreases symptoms – Prevents CHF – Improves mortality

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