Atrial Fibrillation - From Diagnosis to Treatment - St Vincent's Birmingham

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CME Lecture for the medical staff at St Vincent's Hospital.

Atrial fibrillation is a common rhythm disorder. There are many treatment options available today.

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  • Arctic Front demonstrates a simple, straightforward approach to PVI which can be obtained in 4 steps. Step 1: Lead your guide wire/Achieve mapping catheter into the targeted veinStep 2: Inflate the Arctic Front balloon in the left atrium. Once inflated, position the balloon at the PV atrum.Step 3: To assure occlusion, inject dye into the targeted pulmonary vein to make sure the vein is completely occluded. Once assured, ablate the PV for 240 seconds (the dosage used in the STOP AF trial).Step 4: Assess pulmonary vein isolation with the Achieve mapping catheter
  • The majority of STOP AF investigators were first-time users of Arctic Front.As with any new technology or technique, there is a learning curve. Procedural effectiveness is linked to the number of procedures completed. This link is evident when displayed by quartiles with each quartile increasing its treatment success in the sequence those procedures were performed. Treatment success is inclusive of both acute procedural success and freedom from chronic treatment failure at 12 months.In the graph above, each bar represents approximately 41 cryoablation procedures (range 38-43). In the first bar, Quartile 1, there are 25 centers and 43 procedures. These procedures represent the 1st and 2nd Arctic Front procedures the 25 centers performed. The success rate for just these procedures was 56%.In the second bar, Quartile 2, there are 14 centers and 38 procedures. These procedures represent the 3rd – 5th Arctic Front procedures the 14 centers performed, for a success rate of 66%. Only 14/25 centers enrolled to this point. In the third bar there are 10 centers and 42 procedures. These procedures represent the 6 – 11th Arctic Front procedures those 10 centers performed, for a success rate of 69%.Finally, the last bar represents four centers and 40 procedures. These four centers performed at least 12 and up to 23 Arctic Front procedures. Only four centers enrolled this many ablation patients. The success rate for these specific procedures was 90%.
  • Atrial Fibrillation - From Diagnosis to Treatment - St Vincent's Birmingham

    1. 1. Jose Osorio, MD www.theafcenter.com
    2. 2. www.theafcenter.com
    3. 3. Atrial Fibrillation Demographics by Age U.S. population x 1000 Population with AF x 1000 Population with atrial fibrillation 30,000 500 400 U.S. population 20,000 300 200 10,000 100 0 0 <5 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90- >95 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94 Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. Age, yr www.theafcenter.com
    4. 4. 5 4.78 5.16 5.42 5.61 4.34 4 3.80 3 2 2.08 2.26 2.44 2.66 2.94 3.33 1 20 60 20 50 20 45 20 40 20 35 20 30 20 25 20 20 20 15 20 10 20 05 20 00 0 19 95 Adults with AF, MM 6 Year Go A, et al. JAMA. 2001;285:2370-2375. www.theafcenter.com
    5. 5. Atrial Fibrillation Costs to the health care system A LOT!! Average hospital stay = 5 days Mean cost of hospitalization = $18,800 Does not include: Costs of cardioversions/ablations/surgery Costs of drugs/side effects/monitoring Costs of AF-induced strokes Estimated US cost burden 15.7 billion www.theafcenter.com
    6. 6. First Detected Paroxysmal (Self-terminating) Persistent (Not self-terminating) Permanent www.theafcenter.com
    7. 7.  Paroxysmal ◦ few seconds to days, then stops on its own ◦ Typically younger, healthier patients  Healthier “Lone Afib” Persistent ◦ does not stop by itself but will stop with a medication or cardioversion  Permanent ◦ present all the time and cannot be fixed with medication or cardioversion More Comorbidities
    8. 8. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
    9. 9.    Thyroid Disease. Alcohol Consumption. Cardiac Surgery.       15% to 33% of CABG patients 38% to 64% of valve surgery. Valvular Disease. Heart Failure. WPW Hypertension/LVH www.theafcenter.com
    10. 10. www.theafcenter.com
    11. 11. Atrial Fibrillation Obstructive Sleep Apnea 20 – 15 – OSA Cumulative 10 – Frequency of AF (%) 5– No OSA 0– 0 1 2 3 4 5 6 No OSA 8 9 10 11 12 13 14 15 Years Number at Risk OSA 7 844 709 569 478 397 333 273 214 173 134 110 94 70 46 29 8 2,209 1,902 1,616 1,317 1,037 848 641 502 393 296 217 195 130 94 69 28 Cumulative frequency curves for incident atrial fibrillation (AF) for subjects < 65 years of age with and without obstructive sleep apnea (OSA) during an average 4.7 years of follow-up. p = 0.002 Gami, et al. JACC 2007;49:565-71 www.theafcenter.com
    12. 12. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
    13. 13. Atrial Fibrillation and Strokes • 5-fold higher risk of stroke • Over 87% of strokes are thromboembolic • >90% of thrombus originates in the Left Atrial Appendage (LAA) • Stroke is the number one cause of long-term disability and the third leading cause of death in patients with AF www.theafcenter.com
    14. 14. • 500,000 strokes/year in U.S. • Up to 20% of ischemic strokes occur in patients with atrial fibrillation Percent of Total Strokes Attributable to Atrial Fibrillation 35 30 25 20 % 15 10 5 0 50-59 60-69 Stroke 22(18), 1991 70-79 80-89 3000838-7 www.theafcenter.com
    15. 15.  >90% of strokes in AF patients are secondary to LAA emboli www.theafcenter.com
    16. 16. www.theafcenter.com
    17. 17. www.theafcenter.com
    18. 18. www.theafcenter.com
    19. 19. www.theafcenter.com
    20. 20. Cardiac failure Hypertension Age >75 Diabetes Stroke – 2 points Limitation CHADS2 of 0 or 1 patients may still have a moderate risk for stroke www.theafcenter.com
    21. 21. www.theafcenter.com
    22. 22. www.theafcenter.com
    23. 23. Atrial Fibrillation Stroke Prophylaxis www.theafcenter.com
    24. 24. Atrial Fibrillation Challenges in Stroke Prevention • Warfarin • Not always well-tolerated • Less than 50% of patients eligible are being • Time at therapeutic range - low • Prevent Ischemic Strokes  Cause Hemorrhagic Strokes www.theafcenter.com
    25. 25. • Warfarin still cornerstone of therapy • Assuming 51 ischemic strokes/1000 pt-yr • Warfarin prevented 28 strokes at expense of 11 fatal bleeds • Aspirin prevented 16 strokes at expense of 6 fatal bleeds • Warfarin • 60-70% risk reduction vs no treatment • 30-40% risk reduction vs aspirin Cooper: Arch Int Med 166, 2006 Lip: Thromb Res 118, 2006 3000838-10 www.theafcenter.com
    26. 26. Low INR <1.6 Efficacy 4-fold Therapeutic INR 2-3 High INR >3.2 0 20 40 60 80 100 % Bungard: Pharmacotherapy 20:1060, 2001 3000838-14 www.theafcenter.com
    27. 27.  Novel Anticoagulants ◦ Pradaxa – Dabigatran ◦ Xarelto – Rivaroxaban ◦ Eliquis – Apixaban www.theafcenter.com
    28. 28.  Contraindications for anticoagulants: ◦ ◦ ◦ ◦ ◦ Bleeding Hemorrhagic Stroke Frequent Falls Low Platelet Count Recent Surgery Patient’s choice www.theafcenter.com
    29. 29.   What can we offer patients that cannot take oral anticoagulants? Or do not want to take OACs ◦ Left Atrial Appendage Closure www.theafcenter.com
    30. 30. www.theafcenter.com
    31. 31. Pericardial Access www.theafcenter.com
    32. 32. www.theafcenter.com
    33. 33. www.theafcenter.com
    34. 34. www.theafcenter.com
    35. 35. www.theafcenter.com
    36. 36. www.theafcenter.com
    37. 37. www.theafcenter.com
    38. 38. 3000838-18 www.theafcenter.com
    39. 39. Device Day 0 Day 2-14 Preimplant interval Day 45 postimplant Device subject takes warfarin Ongoing to 5 years Device subject has ceased warfarin Control Device subject gets implant Randomize Control subject takes warfarin Day 0 Ongoing to 5 years 3000838-60 www.theafcenter.com
    40. 40. • Primary Efficacy Endpoint • All stroke: ischemic or hemorrhagic • deficit with symptoms persisting more than 24 hours • • or • symptoms less than 24 hours confirmed by CT or MRI Cardiovascular and unexplained death: includes sudden death, MI, CVA, cardiac arrhythmia and heart failure Systemic embolization www.theafcenter.com
    41. 41. Baseline Risk Factors WATCHMAN N= 463 Control N= 244 P-value 1 158/463 (34.1) 66/244 (27.0) 0.3662 2 157/463 (33.9) 88/244 (36.1) 3 88/463 (19.0) 51/244 (20.9) 4 37/463 (8.0) 24/244 (9.8) 5 19/463 (4.1) 10/244 (4.1) 6 4/463 (0.9) 5/244 (2.0) Paroxysmal 200/463 (43.2) 99/244 (40.6) Persistent 97/463 (21.0) 50/244 (20.5) Permanent 160/463 (34.6) 93/244 (38.1) 6/463 (1.3) 2/244 (0.8) 57.3 ± 9.7 56.7 ± 10.1 460 (30.0, 82.0) 239 (30.0, 86.0) CHADS2 Score AF Pattern Unknown LVEF % 0.7623 0.4246 www.theafcenter.com
    42. 42. Randomization allocation (2 device : 1 control) Device Cohort 900 pt-yr Posterior Probabilities Control Events (no.) Total pt-yr Rate (95% CI) Events (no.) Total pt-yr Rate (95% CI) Rel. Risk (95% CI) Noninferiority Superiority 20 582.3 3.4 (2.1, 5.2) 16 318.0 5.0 (2.8, 7.6) 0.68 (0.37, 1.41) 0.998 0.837 Event-free probability 1.0 ITT Cohort: Non-inferiority criteria met WATCHMAN 0.9 Control 0.8 0 365 730 1,095 52 92 12 22 Days 244 463 147 270 3001664-2 www.theafcenter.com
    43. 43.   Oral Anticoagulation is still considered first line therapy Lariat Device ◦ Reserved for patients with Contraindications to oral anticoagulants  Watchman device ◦ Great results in patients that were eligible to take warfarin ◦ May become first line therapy www.theafcenter.com
    44. 44.  What if my patient is back to Sinus Rhythm?  Does he still need anticoagulation?  What about after cardioversion? www.theafcenter.com
    45. 45. 30 Rate Rhythm 25 Mortality, % 20 p=0.078 unadjusted 15 p=0.068 adjusted 10 5 0 0 1 2 3 Rhythm N: 2033 1932 Time (years) 1807 1316 Rate N: 2027 1925 1825 1328 4 5 780 255 774 236 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com
    46. 46. Rate Rhythm Ischemic stroke 77 (5.5%)* 80 (7.1%)* INR < 2.0 27 (35%) 17 (21%) Not taking warfarin 25 (32%) 44 (55%) * p=0.79 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com
    47. 47.   AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients with minimal symptoms Discontinuation of OAC in patients with risk factors for stroke after CV or while on rhythm control drugs is not appropriate ◦ Asymptomatic recurrences www.theafcenter.com
    48. 48. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
    49. 49. ANTITHROMBOTIC RX AND RHYTHM CONTROL OR ? RATE CONTROL www.theafcenter.com
    50. 50. ANTITHROMBOTIC RX AND RHYTHM CONTROL Greater AF Symptoms OR ? RATE CONTROL Minimal or no symptoms www.theafcenter.com
    51. 51. Atrial Fibrillation Treatment Options • Rate Control • Rhythm Control • Medications • Cardioversion • Ablation www.theafcenter.com
    52. 52. www.theafcenter.com
    53. 53. 74 yo medically refractory AF, Echo – Normal AA Rx - Verapamil, Rythmol, Betapace, Norpace I II III V1 RSPV dist RSPV prox * LIPV RA www.theafcenter.com
    54. 54. www.theafcenter.com
    55. 55. Atrial Fibrillation Afib Triggers www.theafcenter.com
    56. 56. Atrial Fibrillation Afib Triggers www.theafcenter.com
    57. 57. www.theafcenter.com
    58. 58. Radiofrequency Ablation Cryoablation www.theafcenter.com
    59. 59. www.theafcenter.com
    60. 60. 1. Access targeted vein 2. Inflate and position 3. Occlude and ablate 4. Assess PVI 60 60 www.theafcenter.com
    61. 61. Delay Increased Delay Isolation Images: Courtesy of Dr. Schwagten, ZNA Middelheim, Belgium (above) and Dr. Vogt, Herz- und Diabeteszentrum NRW, Germany (right) www.theafcenter.com
    62. 62. Lasso Guided PV Isolation Before Ablation During Ablation A PV A PV After Ablation I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1 100 ms A www.theafcenter.com
    63. 63. Pappone C, et,al.J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7. www.theafcenter.com
    64. 64. Freedom from AF Recurrence P<0.001 Pappone C, J Am Coll Cardiol 2003 www.theafcenter.com
    65. 65. QOL Following Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003 www.theafcenter.com
    66. 66. LV Function after AF Ablation Patients with of Without CHF Hsu LF, et.al., NEJM 351:2372-83, 2004 www.theafcenter.com
    67. 67. www.theafcenter.com
    68. 68. CRYO Procedure Experience Impacts Treatment Success P < 0.001 by quartile (Wald) OR = 1.14 for each procedure Treatment Success 100% 90% 69% 66% 80% 56% 60% 40% 20% 0% 25 centers n=43 1st and 2nd procedures 14 centers n=38 3rd – 5th procedures 10 centers n=42 6th – 11th procedures 4 centers n=40 12th – 23rd procedures 69 www.theafcenter.com
    69. 69.  Candidates for ablation ◦ Symptomatic atrial fibrillation despite medical therapy  Paroxysmal Afib  easy to determine  Persistent Afib  Symptoms related to Afib?  Structural Heart Disease / LA dimension  Comorbidities www.theafcenter.com
    70. 70.  AF is rarely life-threatening and is typically recurrent  Treatment goals in symptomatic pts ◦ frequency, duration and severity of recurrences ◦ Reduce Stroke Risk ◦ Minimize risk of tachycardia induced cardiomyopathy www.theafcenter.com
    71. 71. Atrial Fibrillation   Highly Prevalent Condition Treatment ◦ driven by symptoms  Atrial fibrillation ablation ◦ ◦ ◦ ◦   Effective Reduces or eliminates symptoms Reduces risk of stroke Significantly improves quality of life www.theafcenter.com 205-939-0073 www.theafcenter.com

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