Atrial Fibrillation: Update 2007


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  • Above, a lesion created with the AtriCure system is shown on the epicardial surface of an atrial appendage. Lesions created with the AtriCure system are typically very narrow and discreet in nature. When the atrial appendage is invaginated, the endocardial lesion is seen. The electrodes of the AtriCure Handpiece never came in contact with this endocardial surface.
  • Atrial Fibrillation: Update 2007

    1. 1. Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRS Director, Cardiac Electrophysiology Pinnacle Health System and Associated Cardiologists, PC Harrisburg, PA Clinical Associate Professor of Medicine Pennsylvania State College of Medicine October 13, 2007
    2. 2. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis. <ul><ul><li>2% VF </li></ul></ul>Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A. <ul><ul><li>34% Atrial Fibrillation </li></ul></ul><ul><ul><li>18% Unspecified </li></ul></ul><ul><ul><li>6% PSVT </li></ul></ul><ul><ul><li>6% PVCs </li></ul></ul><ul><ul><li>4% Atrial Flutter </li></ul></ul><ul><ul><li>9% SSS </li></ul></ul><ul><ul><li>8% Conduction Disease </li></ul></ul><ul><ul><li>3% SCD </li></ul></ul><ul><ul><li>10% VT </li></ul></ul>
    3. 3. Classification <ul><li>Paroxysmal: recurrent (>2 episodes) that terminate spontaneously within seven days. </li></ul><ul><li>Persistent: AF with duration greater than seven days, or requiring CV (drugs or electrical). Also includes “longstanding persistent AF” (continuous AF lasting greater than one year). </li></ul><ul><li>Permanent: AF in which decision not to restore SR by any means is made. </li></ul>
    4. 4. Atrial Fibrillation: Cardiac Causes <ul><li>Hypertensive heart disease </li></ul><ul><li>Ischemic heart disease </li></ul><ul><li>Valvular heart disease </li></ul><ul><ul><li>Rheumatic: mitral stenosis </li></ul></ul><ul><ul><li>Non-rheumatic: aortic stenosis, mitral regurgitation </li></ul></ul><ul><li>Pericarditis </li></ul><ul><li>Sinus node dysfunction </li></ul><ul><li>Cardiomyopathy </li></ul><ul><ul><li>Hypertrophic </li></ul></ul><ul><ul><li>Idiopathic dilated (? cause vs. effect) </li></ul></ul><ul><li>Post-coronary bypass surgery </li></ul>
    5. 5. Atrial Fibrillation: Non-Cardiac Causes <ul><li>Pulmonary </li></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Thyroid disease: hyperthyroidism </li></ul></ul><ul><ul><li>Electrolyte disorder </li></ul></ul><ul><ul><li>Acidemia, sepsis, other hyperadrenergic states </li></ul></ul><ul><li>Toxic: alcohol (‘holiday heart’ syndrome) </li></ul>
    6. 6. AF: Pathophysiology <ul><li>Wavelets </li></ul>
    7. 7. AF: Pathophysiology Wyse and Gersch, Circulation, 2004;109:3089-3095
    8. 8. AF: Pathophysiology Wyse and Gersch, Circulation, 2004;109:3089-3095
    9. 9. Why Treat AF? <ul><ul><ul><ul><ul><li>Wyse and Gersch, Circulation, 2004;109:3089-3095 </li></ul></ul></ul></ul></ul>
    10. 10. 2006 ACC/AHA/ESC Practice Guidelines: Changes Since 2001 Guidelines <ul><li>Incorporation of major clinical trials. </li></ul><ul><li>Reorganized with emphasis on clinical patient management. </li></ul><ul><li>Incorporation of catheter-based ablation technologies. </li></ul><ul><li>Drug therapy: those approved in N. America and Europe </li></ul><ul><li>Emerging importance of angiotensin inhibition. </li></ul><ul><li>Prophylactic therapies. </li></ul><ul><li>JACC 2006, 48:e149-246 </li></ul>
    11. 11. Rate Control vs. Rhythm Control <ul><li>Studies </li></ul><ul><ul><li>AFFIRM (2002) </li></ul></ul><ul><ul><li>RACE (2002) </li></ul></ul><ul><ul><li>PAF (2000) </li></ul></ul><ul><ul><li>STAF (2003) </li></ul></ul><ul><ul><li>HOT CAFE’ (2004) </li></ul></ul><ul><ul><li>No study demonstrated a difference in quality of life! </li></ul></ul>
    12. 12. Rate Control vs. Rhythm Control <ul><li>However, judgment should be exercised in applying this lack of difference of QOL to individual patients! </li></ul><ul><li>Definition of rate control: less than 100 bpm over at least 18 hr monitoring period, or less than 100% of maximum age-adjusted predicted exercise heart rate. </li></ul><ul><li>Regardless of treatment strategy, antithrombotic therapy is to be continued in indicated patients! </li></ul>
    13. 13. Clinical Management
    14. 14. Clinical Management
    15. 15. Clinical Management
    16. 16. Clinical Management: Which AA Drug?
    17. 17. Catheter and Surgical Ablation of AF
    18. 18. Atrial Fibrillation Ablation: HRS/EHRA/ECAS Expert Consensus Statement <ul><li>Electrophysiologic basis and rationale </li></ul><ul><li>Patient Selection </li></ul><ul><li>Methods </li></ul><ul><li>Complications </li></ul><ul><li>Appropriate follow-up and long-term management </li></ul>
    19. 19. Ablation: Electrophysiologic Basis <ul><li>Traditional Theory: Wavelets </li></ul>
    20. 20. Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, 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 Next     Previous Number 10      September 3, 1998      Volume 339:659-666
    21. 21. Embryology of the Pulmonary Veins
    22. 22. Pulmonary Veins
    23. 23. Catheter Ablation of AF: Different Approaches
    24. 24. Patient Selection <ul><li>Symptomatic AF refractory or intolerant to at least one Class 1 or class 3 antiarrhythmic drug. </li></ul><ul><li>Only absolute contraindication: LA thrombus (TEE before ablation in pts. with persistent AF). </li></ul><ul><li>Other considerations: </li></ul><ul><ul><li>Success less likely in pts. with marked LA dilatation. </li></ul></ul><ul><ul><li>Higher complication rate in very elderly. </li></ul></ul><ul><ul><li>Pts.’ desire to discontinue warfarin is not an appropriate sole indication for ablation. </li></ul></ul>
    25. 25. Complications <ul><li>Cardiac tamponade </li></ul><ul><li>Pulmonary vein stenosis </li></ul><ul><li>Atrio-esophageal fistula </li></ul><ul><li>Phrenic nerve injury </li></ul><ul><li>Thromboembolism </li></ul>
    26. 26. Complications <ul><li>Air embolism </li></ul><ul><li>Post-procedural arrhythmias </li></ul><ul><li>Vascular complications </li></ul><ul><li>Acute coronary occlusion </li></ul><ul><li>Periesophageal vagal injury </li></ul>
    27. 27. Appropriate Follow-up and Long-Term Management: Areas of Consensus <ul><li>IV or LMW heparin bridging. </li></ul><ul><li>Warfarin for at least 2 months in all patients. </li></ul><ul><li>Decision re: warfarin after 2 months based on pt. risk factors NOT presence or absence of AF. </li></ul><ul><li>Long-term warfarin for pts. With CHADS > 2. </li></ul>
    28. 28. Appropriate Follow-up and Long-Term Management: Areas of Consensus <ul><li>Repeat procedures: to be deferred for at least 3 months, if symptoms can be controlled with drugs. </li></ul><ul><li>Definition of major complication: permanent injury, death, requiring intervention for treatment, or prolong or require hospitalization. </li></ul>
    29. 29. Appropriate Follow-up and Long-Term Management: Areas of Consensus <ul><li>Definition of success: freedom from AF/flutter/tachycardia is primary endpoint. Has varied: freedom for AF w/ and w/o sx, 90% reduction of AF burden, presence of AA drugs. </li></ul><ul><li>Recurrence defined as AF/flutter/tachycardias documented lasting > 30 seconds (does not include early recurrence blanking period of 3 months). </li></ul><ul><li>Early recurrence common and not failure: 35%, 40%, 45% at 15, 30, and 60 days respectively. </li></ul><ul><li>Late recurrence (> 1 yr): 5-10%. </li></ul>
    30. 30. Appropriate Follow-up and Long-Term Management: Areas of Consensus <ul><li>Minimal monitoring: </li></ul><ul><ul><li>office F/U 3 months post ablation and Q 6 mos. for 2 yrs. </li></ul></ul><ul><ul><li>Event recorder monitoring for palpitations. </li></ul></ul><ul><ul><li>24-hour Holter monitoring at 3-6 mo. intervals for 1-2 yrs for clinical trials. </li></ul></ul>
    31. 31. Literature Review: Non-randomized trials <ul><li>Single procedure success, %: </li></ul><ul><ul><li>Paroxysmal AF: >60 (38-78) </li></ul></ul><ul><ul><li>Persistent: <30 (22-45) </li></ul></ul><ul><ul><li>Mixed: 16-84 </li></ul></ul><ul><li>Multiple procedure success, %: </li></ul><ul><ul><li>Paroxysmal: >70, (37-88) </li></ul></ul><ul><ul><li>Persistent: >50 (37-88) </li></ul></ul><ul><ul><li>Mixed: 31-80. </li></ul></ul>
    32. 32. Literature Review: 5 Randomized trials <ul><li>2005:70 pts randomized flecainide/sotalol or ablation: </li></ul><ul><ul><li>recurrence= AF w/ or w/o sx. </li></ul></ul><ul><ul><li>AA: 63% </li></ul></ul><ul><ul><li>Abl: 13% </li></ul></ul><ul><li>2006: (146 pts) Persistent AF CV vs. ablation: </li></ul><ul><ul><li>Recurrence: freedom from AF/AFL w/o drugs. </li></ul></ul><ul><ul><li>CV: 58% </li></ul></ul><ul><ul><li>Abl: 74% </li></ul></ul>
    33. 33. Literature Review: 5 Randomized trials <ul><li>2006: (137 pts) Prospective: Role of abl as adjunctive Rx: </li></ul><ul><ul><li>Recurrence: AA: 81%, ablation + AA: 45% </li></ul></ul><ul><li>2006: (199 pts) Randomized, prospective: AA vs ablation: </li></ul><ul><ul><li>Recurrence: AA: 78%, ablation: 14% </li></ul></ul><ul><li>2006: (112 pts) AA vs ablation: </li></ul><ul><ul><li>Recurrence: AA: 93%, ablation: 25% </li></ul></ul><ul><ul><li>63% of AA pts crossed over to ablation </li></ul></ul>
    34. 34. Catheter Ablation of AF <ul><li>J Cardiovasc Electrophysiol. 2006;17:1-6 </li></ul>
    35. 37. Surgical Ablation of AF <ul><li>Concomitant to other open heart operations. </li></ul><ul><li>Stand alone surgery for AF. </li></ul>
    36. 38. Surgical Ablation of AF: Concomitant to other open heart operations <ul><li>Rationale: </li></ul><ul><ul><li>AF is an independent predictor of late mortality. </li></ul></ul><ul><ul><li>AF associated with higher periop mortality. </li></ul></ul><ul><ul><li>Majority of pts with persistent AF before surgery remain unless treated at time of surgery. </li></ul></ul>
    37. 39. Surgical Ablation of AF: Concomitant to Other Open Heart Operations <ul><li>Involves cryoablation, mocrowave, or RF ablation isolation of pulmonary veins and LA lesions (including line to MV-LA isthmus). </li></ul><ul><ul><li>Results: 76%success with LA isthmus lesions, 29% without (mean F/U 41 mos). </li></ul></ul><ul><ul><li>LA appendage occlusion should be strongly considered. </li></ul></ul><ul><ul><li>Results highly variable depending on energy source and completeness of ablation lines. </li></ul></ul>
    38. 40. Stand-alone Surgical Ablation Surgical Maze Procedure Cox JL et al. Ann of Surgery 1996;224(3):267-75.
    39. 41. Cox MAZE III Procedure Cox JL et al. Ann of Surgery 1996;224(3):267-75.
    40. 45. Bipolar clamp ablation
    41. 46. Gross Pathology Atrial Appendage
    42. 47. Stand-alone Surgical Ablation of AF
    43. 48. Thromboembolic Risk: Pathophysiology <ul><li>Wyse and Gersch, Circulation, 2004;109:3089-3095 </li></ul>
    44. 49. Thromboembolic Risk Stratification: Who Needs Anticoagulation?
    45. 50. Thromboembolic Risk Stratification: Who Needs Anticoagulation?
    46. 51. Thromboembolic Risk Stratification: Who Needs Anticoagulation?
    47. 52. Thromboembolic Risk Stratification: Who Needs Anticoagulation?
    48. 53. SUMMARY <ul><li>AF is the most common arrhythmia for which pts. are hospitalized. </li></ul><ul><li>AF is associated with an icreased risk of morbidity and mortality. </li></ul><ul><li>Rhythm control is not necessary in older pts. with minimal or absence of symptoms. </li></ul><ul><li>AA drugs should be chosen based on side effect and proarrhythmic potential, not efficacy (except amio). </li></ul><ul><li>Catheter and surgical ablation are effective in symptomatic pts. unresponsive to medical Rx. </li></ul><ul><li>Antithrombotic therapy guidelines should be followed. </li></ul>