Management of Atrial Fibrillation Management of Atrial Fibrillation - - PowerPoint PPT Presentation

Management of Atrial Fibrillation Management of Atrial Fibrillation

Nitish Badhwar, MD, FACC Nitish Badhwar, MD, FACC University of California, San Francisco University of California, San Francisco Risk Appraisal Forum Risk Appraisal Forum April 23, 2010 April 23, 2010

• Incidence and Disease Burden
• Drug therapy
• Drug therapy
• Role of Catheter ablation
• Outcomes Data

Overall and sex-specific trends in age-adjusted incidence of AF between 1980 and 2000 (age adjustment to the 1990 US population)

Miyasaka, Y. et al. Circulation 2006;114:119-125

Projected Prevalence of Atrial Fibrillation in United States between 2000 and 2050 United States between 2000 and 2050

Miyasaka, Y. et al. Circulation 2006;114:119-125

Incidence of Atrial Fibrillation in different age groups groups

Miyasaka, Y. et al. Circulation 2006;114:119-125

6%

Hospitalization for Arrhythmias (USA)

18% PSVT 6% PVCs Unspecified 4% Atrial Flutter

Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as

34% Atrial Fib ill ti 9% SSS

with arrhythmia as principal diagnosis.

Fibrillation 8% Conduction Conduction Disease 3% SCD 10% VT

2% VF

Bialy D et al. JACC. 1992;19:41A

Presence of Heart Disease in Consecutive Presence of Heart Disease in Consecutive O t ti t ith AF O t ti t ith AF Outpatients with AF Outpatients with AF

35% 65%

Lone AF Heart di

Prystowsky et al. Circulation. 1996;94:I-191

Symptom Profile

• 3 patients (2%) had non-lethal cardiac arrest
• The most frequent symptoms were: palpitations

(96%), dizziness (75%), and shortness of breath (47%)

• 20% of subjects (33 of 167) reported at least 1

20% of subjects (33 of 167) reported at least 1 episode of syncope which was preceded by palpitations Symptoms were significantly (p< 0 05) different in the

• Symptoms were significantly (p< 0.05) different in the

AF/AFL group vs. other types of SVT

• Despite a low incidence of associated heart disease,

and good LV function, there was a high frequency of disabling, potentially life-threatening symptoms associated with episodes of SVT

Wood et al., Am J Cardiol. 1997:79(2):145 Wood et al., Am J Cardiol. 1997:79(2):145-

• 9

9. .

Consequences of Atrial Fibrillation q

• Arrhythmia- associated symptoms
•  LV function, exercise tolerance, and

, , QOL

• Tachycardia- mediated cardiomyopathy
• 5- fold  in stroke risk
• Significant burden to healthcare system

g y

Classification of Atrial Fibrillation

Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:1603-1605

Management of Atrial Fibrillation g

Therapy goals may include:

• Control of the heart rate

(symptom-reduction, rate-control) (symptom reduction, rate control)

• Restoration and maintenance of normal sinus

rhythm (intervention and termination, rhythm-control)

• Reduction in thrombo-embolic complications

(risk reduction for stroke)

• Incidence and Disease Burden
• Drug therapy
• Drug therapy
• Role of Catheter ablation
• Role of Imaging

Percentage of Strokes Associated with Atrial Fib ill ti Fibrillation

Wolf P, Abbott RD, Kannel WB. Arch Intern Med. 1987;147:1561-1564.

Risk of Stroke and Bleeding with Warfarin in At i l Fib ill ti Atrial Fibrillation

4 4.5 5 Placebo Warfarin 2 5 3 3.5 4 Placebo Warfarin 1.5 2 2.5 0.5 1

Stroke Bleeding

Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.

Risk factors for Stroke in Patients with AF Risk factors for Stroke in Patients with AF

• High Risk

g

– Previous CVA, TIA – Rheumatic mitral stenosis

• Moderate Risk

– Age > 75 g – HTN – DM – CHF, EF < 35%

• Hyperthyroidism
• HOCM

AF Guidelines. 2006.

Dabigatran vs Warfarin in Atrial Fibrillation g

Connolly et al. N Eng J Med. 2009;361:1139-51.

Newer Rx for Stroke Prevention Newer Rx for Stroke Prevention

• Left Atrial Appendage Occluding devices

– Watchman device – Place device

• Drugs

– Oral direct thrombin inhibitors (Dabigatran) – Direct factor Xa inhibitors

Parenteral (Fondarin )

• Parenteral (Fondarinux)
• Oral (Razaxaban)

– Odiparcil p

Pharmacological cardioversion Pharmacological cardioversion g

• Ibutilide

Ibutilide

• Parenteral procainamide, flecainide,

f t l l propafenone, sotalol

• Dofetilide
• Pill in the pocket (oral)

– Flecainide (200 / 300 mg) – Flecainide (200 / 300 mg) – Propafenone (450 / 600 mg) – Need AV nodal blockers

Newer Drugs for Rhythm Control Newer Drugs for Rhythm Control g y g y

• Dronederone

Dronederone

• Azimilide
• Trecetilide
• Atrial specific

p

– Tediasamil RSD 1235 – RSD 1235 – ZP 123 (gap junction enhancer) – AVE 0118

AFFIRM

Atrial Fibrillation Follow-up: Investigation of Rhythm Management

• Entry Criteria

PAF Persistent AF

• Outcomes Data

Survival

–

PAF, Persistent AF

–

< 65 w/ risk fx, or >65 w/o

–

6 hr of AF

–

Survival

–

Total mortality

–

QoL, cost

–

Disabling stroke, hemorrhage, SCD

• Treatment Arms

–

Randomized, multicenter

–

Rhythm + anticoag g , g ,

• Study Results

–

N=4060; (~2030 each group)

–

Rate + anticoag

–

Rhythm = AADs or CV, devices & RFA rarely used

–

Mean f/u 3.5 yrs

–

Rhythm control offered no survival benefit More adverse events (CVA death RFA rarely used

–

Rate = ß, & Ca+ channel blkrs, digoxin, 5% ablate & pace, 6MWD

–

More adverse events (CVA, death, hospitalizations) in Rhythm arm

NEJM 2002;347:1825-1833

• Incidence and Disease Burden
• Drug therapy
• Drug therapy
• Role of Catheter ablation
• Role of Imaging

Ablation for Atrial Fibrillation

• AV nodal ablation for rate control
• Ablation of precipitating arrhythmia

(tachycardia induced tachycardia) (tachycardia induced tachycardia)

• Ablation to cure atrial fibrillation

AV Junction Ablation

Singer: Interventional Electrophysiology. Williams & Wilkins 1997; 328.

Ablate (AV Junction) and Pace ( )

• Clinical improvement

– Fewer symptoms – Better exercise tolerance Better exercise tolerance – Improved QOL

• Improved hemodynamics

CO increased – CO increased – Improved EF – Small but real incidence of post-procedure SCD

PAVE T i l

• PAVE Trial

– Biventricular pacing post ablation improved EF – RV pacing decreased EF

Ablation for Atrial Fibrillation

• AV nodal ablation for rate control
• Ablation of precipitating arrhythmia

(tachycardia induced tachycardia) (tachycardia induced tachycardia)

• Ablation to cure atrial fibrillation

Tachycardia-Induced Tachycardia Tachycardia Induced Tachycardia

• One tachycardia degenerates into another

One tachycardia degenerates into another

• Examples:

–Atrial flutter and atrial tachycardia into AF Atrial flutter and atrial tachycardia into AF –AV node reentry into AF –AV reentry into AF

• Treating the initiating tachycardia can help

prevent future episodes of AF

UC SF

AVNRT AVNRT Atrial Fibrillation Atrial Fibrillation

Sauer et al. Circulation 2006;114:191 Sauer et al. Circulation 2006;114:191-

• 195.

195.

Yang Y et al. AJC 2003;91(1):46 Yang Y et al. AJC 2003;91(1):46-

• 52

52

Ablation for Atrial Fibrillation

• AV nodal ablation for rate control
• Ablation of precipitating arrhythmia

(tachycardia induced tachycardia) (tachycardia induced tachycardia)

• Ablation to cure atrial fibrillation

Cut and Sew Maze Procedure Cut and Sew Maze Procedure

Ad, N and Cox, JL. J Card Surg 2004;19:196 Ad, N and Cox, JL. J Card Surg 2004;19:196-

• 200

200

Long term efficacy of Cox Maze III Long term efficacy of Cox Maze III

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

• 28.

28.

Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation

Wolf et al. Wolf et al. J Thorac Cardiovasc Surg.2005;130:797-802.

Catheter Maze (LA) procedure ( ) p

• 42 patients in study, 40 treated
• 36 initially successful procedures 4 failures
• 36 initially successful procedures, 4 failures
• 4 total deaths, all unrelated to procedure
• 9 severe complications, 2 mild

– 3 CVA’s – 1 hemodynamic collapse – 1 pericardial effusion / pericardiocentesis 1 infection related – 1 infection related – 1 ARDS – 1 anaphylactic reaction – 1 blood loss / transfusion – 1 blood loss / transfusion – 2 pressure sores

Focal Atrial Fibrillation Focal Atrial Fibrillation

Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins Originating in the Pulmonary Veins

Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Mélè H i i M D Gill Q i i M D S é h G i M D Al i L M M D Mélè H i i M D Gill Q i i M D S é h G i M D Al i L M M D Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Philippe Le Métayer, M.D., and Jacques Clémenty, M.D. Philippe Le Métayer, M.D., and Jacques Clémenty, M.D.

1998 1998

Catheter Ablation for Atrial Fibrillation

Evolution of Catheter Ablation Techniques for At i l Fib ill ti Atrial Fibrillation

• Focal
• Segmental

g

• Circumferential
• Circumferential + Linear (chronic AF)

( )

• Electrophysiological substrate

(fractionated signals) ( g )

• Spectral analysis of dominant frequency
• Autonomic ganglia modulation

uto o c ga g a

• du at o

Location of Left Atrial Ganglionated Plexuses

Superior Left GP

RSPV LSPV

RPA LPA

Posterior Surface

RSPV

Surface Anterior Surface PA

RIPV LIPV

Projection

Inferior

Modified from Armour JA, et al The Anatomical Record 1997

Inferior Left GP

Autonomic ganglia modulation during Autonomic ganglia modulation during catheter ablation for AF catheter ablation for AF

Intracardiac ultrasound showing tenting of the inter Intracardiac ultrasound showing tenting of the inter-

• atrial septum during transseptal catheterization

atrial septum during transseptal catheterization Intracardiac ultrasound showing tenting of the inter Intracardiac ultrasound showing tenting of the inter-

• atrial septum during transseptal catheterization

atrial septum during transseptal catheterization atrial septum during transseptal catheterization atrial septum during transseptal catheterization atrial septum during transseptal catheterization atrial septum during transseptal catheterization

Phased Phased-

• Array Intracardiac Echocardiography

Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Monitoring During Pulmonary Vein Isolation in Patients With Atrial Fibrillation Patients With Atrial Fibrillation

Marrouche et al. Circulation.2003;107:2710 Marrouche et al. Circulation.2003;107:2710-

• 2716.)

2716.)

Registration of CT derived 3D left atrial model Registration of CT derived 3D left atrial model with non contact mapping system with non contact mapping system with non contact mapping system with non contact mapping system

Left Pulm Left Pulm Left Pulm Left Pulm Right Pulm Right Pulm Right Pulm Right Pulm Left Pulm Left Pulm Veins Veins Left Pulm Left Pulm Veins Veins Right Pulm Right Pulm Veins Veins Right Pulm Right Pulm Veins Veins Esophagus Esophagus

3D (Navix) view 3D (Navix) view CT view CT view

CT Analysis of the anatomy of Left Atrium and CT Analysis of the anatomy of Left Atrium and Esophagus Esophagus p g p g

Lemola et al.Circulation.2004;110:3655 Lemola et al.Circulation.2004;110:3655-

• 3660.

3660.

Catheter Ablation within the CT Scan Catheter Ablation within the CT Scan Catheter Ablation within the CT Scan Catheter Ablation within the CT Scan

LUPV LUPV RUPV RUPV RUPV RUPV LAA LAA LLPV LLPV RLPV RLPV Mitral Annulus Mitral Annulus Mitral Annulus Mitral Annulus

Role of Digital Enhanced MRI to Assess Left Role of Digital Enhanced MRI to Assess Left At i l St t l R d li At i l St t l R d li Atrial Structural Remodeling Atrial Structural Remodeling

Normal Normal Moderate Moderate Severe Severe

Oakes et al. Oakes et al. Circulation.2009;119:1758 Circulation.2009;119:1758-

• 1767.

1767.

Remote Navigation (Stereotaxis)

• Afib incidence and disease burden
• Role of catheter ablation
• Role of catheter ablation
• Role of imaging in ablation
• Outcomes data

Management of Atrial Fibrillation g

Measurable Outcomes

• Time to First Recurrence

– Requires reliable monitoring – AF episodes tend to “cluster”

• Frequency of Episodes

– Requires reliable detection for both symptomatic and asymptomatic episodes

• Duration of Episodes
• Duration of Episodes

– Requires reliable monitoring

• AF Burden
• AF Burden

– Dependent upon accuracy of detection and duration recording

Freedom from AF After Circumferential Pulmonary Freedom from AF After Circumferential Pulmonary Vein Ablation: Outcomes From a Controlled Vein Ablation: Outcomes From a Controlled Nonrandomized Long Nonrandomized Long-

• Term Study

Term Study

Pappone et al. JACC.2003;42:185 Pappone et al. JACC.2003;42:185-

• 197.

197.

Quality of Life after Ablation Q y

• Patients baseline QoL scores were lower than US

normative values At b li ti t ’ ith AF & AFL

• At baseline, patients’ scores with AF & AFL were

lowest compared to other arrhythmia pts

• Patients improved significantly post-procedure

Patients improved significantly post procedure

• Significant decrease in healthcare use & use of

AADs in 6 mth following RFA

• LV function & exercise tolerance significantly

improved

Wood et al., Circ 2000;101:1138 Wood et al., Circ 2000;101:1138-

• 1144. Bubien et al., Circ 1996; 94(7):1585
• 1144. Bubien et al., Circ 1996; 94(7):1585-
• 91.

91.

Radiofrequency Ablation vs Antiarrhythmic Radiofrequency Ablation vs Antiarrhythmic Drugs as First Drugs as First-

• Line Treatment of Symptomatic

Line Treatment of Symptomatic g y p y p Atrial Fibrillation: A Randomized Trial Atrial Fibrillation: A Randomized Trial

Wazni et al. JAMA.2005;293:2634 Wazni et al. JAMA.2005;293:2634-

• 2640.

2640.

Worldwide Survey of the Methods, Efficacy, Worldwide Survey of the Methods, Efficacy, and Safety of Catheter Ablation for Human and Safety of Catheter Ablation for Human y Atrial Fibrillation Atrial Fibrillation

Cappato et al. Circulation.2005;111:1100 Cappato et al. Circulation.2005;111:1100-

• 1105.

1105.

Worldwide Survey of the Methods, Efficacy, Worldwide Survey of the Methods, Efficacy, and Safety of Catheter Ablation for Human and Safety of Catheter Ablation for Human y Atrial Fibrillation Atrial Fibrillation

Cappato et al. Circulation.2005;111:1100 Cappato et al. Circulation.2005;111:1100-

• 1105.

1105.

Cheema et al. Cheema et al. J Interv Card Electrophysiol.2006;15:145-155.

Success Based on Type of Atrial Fibrillation Success Based on Type of Atrial Fibrillation

Cappato et al. Circ Arrhythm Electrophysiol. 2010 Cappato et al. Circ Arrhythm Electrophysiol. 2010

Complications p

• CVA, TIA, air embolism
• Left sided atrial arrhythmias
• Left sided atrial arrhythmias
• Pulmonary vein stenosis
• AV fistulae, femoral pseudoaneurysm

p y

• Coronary artery occlusion
• Death (1/1000)

M h i l

• Mechanical

– Perforation

• During transseptal puncture- aorta, LA

D i bl ti LA d

• During ablation- LA appendage
• Atrio Esophageal Fistula

– Phrenic nerve paralysis V l d – Valve damage

Who is a candidate for AF Catheter Abl ti ? Ablation?

• Paroxysmal

– Symptomatic – Failed antiarrhythmics

• Chronic

– Highly symptomatic – Poor hemodynamics T h di i d d di th – Tachycardia induced cardiomyopathy – Failed antiarrhythmics

Preprocedure work up Preprocedure work up

• Echo, TEE
• Stress test
• CT / MRI
• Anticoagulation for I month prior to

g p procedure

• Labs

– TSH – Creatinine

Future Considerations

• New ablation techniques
• New ablation techniques

– Cryoablation – Laser balloon, HIFU ase ba oo , U – Robotic + Linear ablation techniques

• Hybrid procedures (Surgical+catheter)

y p ( g )

• CABANA Trial

– Drugs vs Ablation, 3000 pts g p – Primary end point total mortality – Secondary end point cardiovascular mortality, t k MI i bl di di t stroke, MI, serious bleeding, cardiac arrest

Summary

Chemical

Drugs

Chemical Cardioversion Electrical Cardioversion

20 30 40 50 60 70 80 90 100%

% Success

Focal AT Ablation Flutter Ablation Linear Ablation

% Success

Focal AT Ablation PV Quadrant/ Total Isolation

Thank you Thank you