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atrial fibrillation management and treatment

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  • Figure 1. Cumulative Incidence of Trial Outcomes, According to Treatment Group. Panel A shows the cumulative incidence of the primary end point (stroke, myocardial infarction, non-central nervous system systemic embolism, or death from vascular causes). The relative risk for aspirin plus clopidogrel, as compared with aspirin alone, was 0.89 (95% confidence interval [CI], 0.81 to 0.98; P=0.01). Panel B shows the cumulative incidence of stroke. The relative risk for aspirin plus clopidogrel, as compared with aspirin alone, was 0.72 (95% CI, 0.62 to 0.83; P&lt;0.001). The insets show the data on a compressed scale. <br />
  • Figure 1. Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism, According to Treatment Group. <br />
  • Background: The impact of atrial fibrillation (AF) on <br /> mortality, stroke, and medical costs is unknown. <br /> Methods: We conducted a prospective cohort study of <br /> hospitalized Medicare patients with AF and 1 other cardiovascular <br /> diagnosis (CVD) compared with a matched <br /> group without AF (n=26 753), randomly selected in 6 <br /> age-sex strata from 1989 MedPAR files of more than 1 <br /> million patients diagnosed as having AF. Stroke rates were <br /> also determined in another cohort free of CVD <br /> (n=14 267). Total medical costs after hospitalization were <br /> available from a 1991 cohort. Cumulative mortality, stroke <br /> rates, and costs following index admission were adjusted <br /> by multivariate and proportional hazard regression <br /> analyses. <br /> Results: Mortality rates were high in individuals with <br /> CVD, ranging from 19.0% to 52.1% in 1 year. Adjusted <br /> relative mortality risk was approximately 20% higher in <br /> patients with AF in all age-sex strata during each of the 3 <br /> years studied (P,.05). Incidence of stroke was high in individuals <br /> with CVD, 6.2% to 15.4% in 1 year, with and <br /> without AF, and was at least 5-fold higher than in individuals <br /> without CVD. In those with CVD, stroke rates were <br /> approximately 25% higher in women with AF (P,.05) but <br /> only 10% higher in men. Adjusted total Medicare spending <br /> in 1 year was 8.6- to 22.6-fold greater in men, and 9.8- <br /> to 11.2-fold greater in women with AF (P,.05). Secondand <br /> third-year costs were increased as well. <br /> Conclusion: Prevention of AF and treatment of patients <br /> with AF and associated CVD may yield benefits in <br /> reduced mortality and stroke as well as reducing health <br /> care costs. <br /> Arch Intern Med. 1998;158:229-234 <br />
  • Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. <br /> Dittrich HC, Erickson JS, Schneiderman T, Blacky AR, Savides T, Nicod PH. <br /> Division of Cardiology, University of California San Diego Medical Center 92103. <br /> Previous studies have suggested that success of elective direct-current cardioversion for atrial fibrillation (AF) can be predicted from clinical features and M-mode echocardiographic left atrial diameter. We evaluated clinical variables as well as M-mode and 2-dimensional echocardiographic measurements of atrial size in 85 patients undergoing electrical cardioversion for AF. Of 65 patients who were initially converted to sinus rhythm, 45 (69%) and 38 (58%) remained in sinus rhythm at 1 and 6 months, respectively. No historical feature predicted initial success, although patients with cardiomyopathy or pulmonary disease underlying their AF had significantly lower success rates compared with those having other etiologies. Furthermore, no M-mode or 2-dimensional echocardiographic measurements of atrial size predicted initial success of cardioversion. Maintenance of sinus rhythm at 1 month was related to short duration of AF before cardioversion (less than 3 months vs greater than 12 months, p less than 0.05). Left atrial area and long axis dimension by 2-dimensional echocardiography were significantly larger in patients remaining in sinus rhythm than in those who had reverted to AF at 1 month (28 +/- 7 vs 24 +/- 5 cm2 and 65 +/- 9 vs 59 +/- 8 mm, respectively, both p less than 0.05), but overlap was great. No significant difference in atrial dimensions was noted at 6-month follow-up. It appears that, although no clinical or echocardiographic variable predicts initial success for cardioversion of AF, duration of AF does predict maintenance of sinus rhythm 1 month after initial success <br />
  • So our unifying theory of atrial fibrillation is that it is multifactorial. <br />
  • Figure 1. Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group. Time zero is the day of randomization. Data have been truncated at five years. <br />
  • Figure 2. Hazard Ratios for Death in Prespecified Subgroups. The numbers in the groups do not total 4060 for all variables because of incomplete reporting. The ratios shown are for the rhythm-control group as compared with the rate-control group. <br />
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Atrial fibrillation 2014 Atrial fibrillation 2014 Presentation Transcript

  • Atrial Fibrillation: 2014 Emerging Concepts New Treatment Paradigms John Hakim, MD, FACC
  • Atrial Fibrillation Talk Goals Describe etiology of Atrial fibrillation Treatment Goals for Atrial Fibrillation – – Novel Anticoagulants Rate Control/ Rhythm Control Advances in Therapy for Atrial fibrillation
  • The hallmark of AF is chaotic atrial impulses leading to irregularly irregular ventricular contraction, usually with incessant tachycardia
  • OVERVIEW Atrial fibrillation is a progressive disease Atrial fibrillation has hemodynamic and myocardial consequences (i.e., reduced cardiac output and heart failure) There is significant morbidity and mortality consequences -increased hospitalizations -reduced quality of life -increased risk of thromboembolism and stroke (accounts for 75,000 strokes per year in the United States alone) -decreased survival (AF is associated with increased mortality, but whether it is the cause or an innocent bystander is not well established)1-8 Atrial fibrillation is a treatable disorder, especially with early intervention What’s new in atrial fibrillation treatment 1 Benjamim EJ, et al. Impact of AF on the risk of death: The Framinham Heart Study. Circulation. 1998; 98: 946-52. 2 Gajewski J, et al. Mortality in an insured population with AF. JAMA. 1981; 245: 1540-44. 3 Krahn AD, et al. The natural history of AF. Am J Med. 1995; 98: 476-84. 4 Flegel KM, et al. Risk of stroke in non-rheumatic AF. Lancet. 1987; 1: 526-9. 5 Kulbertus HE, et al. AF in elderly, ambulatory patients. AF; 1982: 148-57. 6 Lake FR, et al. AF and mortality in an elderly population. Aus N Z J Med. 1989; 19: 321-6. 7 Kannel WB, et al. Epidemiologic features of chronic AF: the Framingham Study. NEJM 1982; 306: 1018-22. 8 Kitchin AH, et al. Longitudinal survey of ischemic heart disease in randomly selected older population. Br Heart J 1977; 39: 889-93.
  • Classification and Patterns of AF Paroxysmal: terminates spontaneously, typically duration is <7 days (most<24 hours). May be recurrent. Persistent: medication or electrical intervention is required to restore sinus rhythm; does not self-terminate. Typically lasts > 7 days. May be recurrent. Permanent: sinus rhythm cannot be restored or maintained despite intervention. * Evaluate for thrombotic risk each of these situations.*
  • Causes of Atrial Fibrillation Hypertension Heart attacks/ CAD Valvular Heart Disease Congenital heart defects Hyperthyroid or other metabolic imbalance Exposure to stimulants such as medications, caffeine or tobacco, or to alcohol (holiday heart) Sick sinus syndrome — improper functioning of the heart's natural pacemaker Emphysema or other lung diseases CABG/ Previous heart surgery Viral infections /Pericarditis Stress due to pneumonia, surgery or other illnesses (Catecholamine) Pulmonary Embolus Pneumonia Sleep Apnea Pericarditis Lone A fib (younger people) Left ventricular Hypertrophy Cardiomyopathy CHF –Systolic or Diastolic Idiopathic – mostly in younger people – Lone Atrial Fib Familial Predisposition. Glucocorticoids Electrolyte abnormalities (especially Low Mg+2) Atrial fibrosis from Sarcoid, collegen vascular disease, infiltrating diseases
  • Risk Factors for AF: Diabetes AF is 44% more prevalent and 38% more likely to develop when diabetes was present in an adult population Prevalence and incidence of AF in 17,372 patients with diabetes and in the same amount of age- and sex-matched controls without type 2 diabetes included in a Kaiser Permanente diabetes registry. The researchers followed patients without AF for the comparison of AF incidence while controlling for known risk factors. Prevalence for AF was significantly higher among patients with diabetes compared with those without (3.6% vs. 2.5%; P<.0001). Over 7.2 years, patients with diabetes without AF at baseline developed AF at an age- and sex-adjusted rate of 9.1 per 1,000 personyears vs. 6.6 per 1,000 person-years for patients without diabetes. Diabetes was associated with a 26% increased risk for AF among women after adjusting for other risk factors (HR=1.26; 95% CI, 1.081.46). Diabetes was not a statistically significant risk factor among men. Men had a higher prevalence of AF in all age groups regardless of diabetes
  • HAS BLED SCORE
  • HAS BLED score Hypertension History(Uncontrolled, >160 mmHg systolic) Renal DiseaseDialysis, transplant, Cr >2.6 mg/dL or >200 µmol/L Liver Disease: Cirrhosis, Bilirubin >2x Normal, AST/ALT/AP >3x Normal Stroke History Prior Major Bleeding or Predisposition to Bleeding Labile INR(Unstable/high INRs), Time in Therapeutic Range <60%   Age > 65 Medication Usage Predisposing to Bleeding(Antiplatelet agents, NSAIDs) Alcohol Usage History≥ 8 drinks/week Risk was 0.9% in one validation study and 1.13 bleeds per 100 patientyears in another validation study.
  • Original Article Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation --- ACTIVE TRIAL • A randomized trial enrolled 7554 patients with AF who were at increased risk of stroke but not candidates for vitamin K antagonists • Participants were assigned to aspirin or aspirin plus clopidogrel • At a median of 3.6 years, the risk of major vascular events decreased significantly with clopidogrel, primarily because of reduced risk of stroke • The risk of major bleeding increased significantly with clopidogrel N Engl J Med Volume 360(20):2066-2078 May 14, 2009
  • Cumulative Incidence of Trial Outcomes, According to Treatment Group The ACTIVE Investigators. N Engl J Med 2009;360:2066-2078
  • The ACTIVE Investigators In patients with atrial fibrillation for whom vitamin K–antagonist therapy was unsuitable, the addition of clopidogrel to aspirin reduced the risk of major vascular events, especially stroke, and increased the risk of major hemorrhage.
  • Change to 2011 Afib guidelines
  • Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism, According to Treatment Group Connolly SJ et al. N Engl J Med 2009;361:1139-1151
  • Dabigatran versus Warfarin in Patients with Atrial Fibrillation (NEJM 9/7/2009) In patients with AF, dabigatran given at a dose of 110 mg was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major hemorrhage. Dabigatran administered at a dose of 150 mg, as compared with warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage
  • Primary Outcome Stroke (ischemic or hemorrhagic) or systemic embolism P (non-inferiority)<0.001 21% RRR Apixaban 212 patients, 1.27% per year Warfarin 265 patients, 1.60% per year HR 0.79 (95% CI, 0.66–0.95); P (superiority)=0.011 No. at Risk Apixaban Warfarin 9120 9081 8726 8620 8440 8301 6051 5972 3464 3405 1754 1768
  • Major Bleeding ISTH definition 31% RRR Apixaban 327 patients, 2.13% per year Warfarin 462 patients, 3.09% per year HR 0.69 (95% CI, 0.60–0.80); P<0.001 No. at Risk Apixaban Warfarin 9088 9052 8103 7910 7564 7335 5365 5196 3048 2956 1515 1491
  • Stroke and Bleeding in Atrial Fibrillation with Chronic Kidney Disease Jonas Bjerring Olesen, M.D., et al N Engl J Med 2012; 367:625-635August 16, 2012 • Chronic kidney disease was associated with an increased risk of stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation. • Warfarin treatment was associated with a decreased risk of stroke or systemic thromboembolism among patients with chronic kidney disease, whereas warfarin and aspirin were associated with an increased risk of bleeding.
  • Novel Anticoagulants in Renal failure. ELIQUIS (apixaban) (25% URINE /Renal 75% Hepatic metabolism: The dosing adjustment for moderate renal impairment is described above The recommended dose for patients with end-stage renal disease (ESRD) maintained on hemodialysis is 5 mg twice daily. Reduce dose to 2.5 mg twice daily if one of the following patient characteristics (age ≥80 years or body weight ≤60 kg) is present. In Apixaban ( Eliquis) if two of the following present reduce the dose to 2.5 bid. ( Creatinine >1.5, age ≥80 years or body weight ≤60 kg) Pradaxa For patients with creatinine clearance (CrCl) >30 mL/min, the recommended dose of PRADAXA is 150 mg taken orally, twice daily. For patients with severe renal impairment (CrCl 15-30 mL/min), the recommended dose of PRADAXA is 75 mg twice daily [see Use in Specific
  • Novel Anticoagulants in Renal failure. Apixaban (ELIQUIS) (25% Renal 75% Hepatic metabolism) In Apixaban ( Eliquis) if two of the following present reduce the dose to 2.5 bid. ( Creatinine >1.5, age ≥80 years or body weight ≤60 kg) The recommended dose for patients with end-stage renal disease (ESRD) maintained on hemo dialysis is 5 mg twice daily. Reduce dose to 2.5 mg twice daily if one of the following patient characteristics (age ≥80 years or body weight ≤60 kg) is present. Xarelto ( 51% Renal 49% hepatic metabolism) Patients with CrCl 30 to 50 mL/min were administered XARELTO 15 mg once daily resulting in serum concentrations of rivaroxaban and clinical outcomes similar to those in patients with better renal function administered XARELTO 20 mg once daily. ( Patients with Cr Cl <30 ml/min not studied). Dabigantran (Pradaxa) (80% renal cleared) For patients with creatinine clearance (CrCl) >30 mL/min, the recommended dose of PRADAXA is 150 mg taken orally, twice daily. For patients with severe renal impairment (CrCl 15-30 mL/min), the recommended dose of PRADAXA is 75 mg twice daily . Dosing recommendations for patients with a CrCl <15 mL/min or on dialysis cannot be provided.
  • Rate versus Rhythm control Benefits of rhythm control include: decreased hospitalizations, improved cardiac function, improved exercise tolerance, and improvement in quality of life Consequences of failure to maintain sinus rhythm: Atrial remodeling and permanent atrial fibrillation The goals of anti-arrhythmic therapy to maintain normal sinus rhythm should be: 1. To reduce the frequency, severity, and duration of AF 2. effects to a degree acceptable to the patient To do so with the lowest likelihood of adverse
  • If clinicians do not try to maintain normal sinus rhythm in the present, it becomes more difficult over time. Patients converted to normal sinus rhythm within 3 months have a 69% chance of remaining in sinus rhythm at 6 months compared to only 27% if they are allowed to remain in AF for > 12 months.2 Dittrich HC, et al. Am J Cardiol 1989; 63: 193-7. 2
  • Therapeutic Goals in the Treatment of AF •Prevent Stroke/TE •Prevention of CHF •Relief of symptoms •Improved quality of life •Reduction in cost of care to medical system
  • Atrial Fibrillation: A Unifying Theory Focal triggering initiation Multiple wavelets for AF maintenance Parasympathetic effects on atrial substrate Varying importance among population of lone, vagally-mediated, PAF, persistent , and permanent atrial fibrillation.
  • Electrophysiologic mechanisms of AF AUTONOMIC INFLUENCE PV AND LA TRIGGERS WAVELETS AND ROTORS FOCAL TRIGGERS LEADING TO INITIATION OF REENTRY AND WAVELETS
  • Substrate Evolution Hints at a PatientTailored approach -The role of pulmonary veins in the perpetuation and initiation of paroxysmal AF have been demonstrated; hence the effectiveness of pulmonary vein isolation techniques in this cohort of patients. -As atrial fibrillation progresses to persistent and permanent, the role of “muscle, scar, and fibrosis”, that is structural disease, becomes more prominent, hence a hybrid approach is more effective both targeting the substrate and the triggers Fisher JD, et al. PACE 2006; 29: 523. Wyse DG, Gersh BJ. Circ 2004; 109: 3089.
  • A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators NEJM 347:1825-1833 December 5, 2002
  • AFFIRM Trial There are two approaches to the treatment of AF: one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm, and the other is the use of rate-controlling drugs, allowing AF to persist. In both approaches, the use of anticoagulant drugs is recommended. AFFIRM was a randomized, multicenter comparison of these two treatment strategies in patients with AF and a high risk of stroke or death. The primary end point was overall mortality. Results A total of 4060 patients (mean [±SD] age, 69.7±9.0 years) were enrolled in the study; 70.8 percent had a history of hypertension, and 38.2 percent had coronary artery disease. Of the 3311 patients with echocardiograms, the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percentgroup of high-risk patients.
  • Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002;347:1825-1833
  • Hazard Ratios for Death in Prespecified Subgroups The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002;347:1825-1833
  • Result of AFFIRM Trial . There were 356 deaths among the patients assigned to rhythmcontrol therapy and 310 deaths among those assigned to ratecontrol therapy (mortality at five years, 23.8 percent and 21.3 percent, respectively; hazard ratio, 1.15 [95 percent confidence interval, 0.99 to 1.34]; P=0.08). More patients in the rhythm-control group than in the rate-control group were hospitalized, and there were more adverse drug effects in the rhythm-control group as well. In both groups, the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic. Conclusions Management of AF with the rhythm- control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this (NEJM 2002)
  • Which Strategy is Better in Heart Failure Patients? Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure Trial NEJM 358:2667-2677 June 19, 2008
  • Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure (AF- CHF TRIAL) NEJM 2008; 358: 2667-2677 Common practice is to restore and maintain sinus rhythm in patients with AF and heart failure. This approach is based in part on data indicating that AF is a predictor of death in patients with heart failure and suggesting that the suppression of AF may favorably affect the outcome. Methods A multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with EF 35% or less, symptoms of congestive heart failure, and a history of AF. The primary outcome was the time to death from cardiovascular causes. as compared with a rate-control strategy
  • RESULTS of AF CHF Results A total of 1376 patients were enrolled (682 in the rhythmcontrol group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes also did not differ significantly between the two treatment strategies: – All-cause death: 32% and 33%, P = 0.73 – Stroke: 3% and 4%, P = 0.32 – Worsening heart failure: 28% and 31%, P = 0.17 – Composite of CV death, stroke, worsening heart failure: 43% and 46%, P = 0.20 There were also no significant differences favoring either strategy in any predefined subgroup.
  • AF CHF results Conclusions In patients with AF and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of cardiovascular death. Comment: The investigators caution that, "Our results cannot be generalized to patients with heart failure and preserved left ventricular function.“ NEJM 358:2667-2677 June 19, 2008
  • Why hasn’t rhythm control worked in trials? Drugs used in trials don’t guarantee rhythm control Toxicity of Anti arrythmic drugs contribute to lack of benefit of rhythm control groups. AF may be a marker of poor prognosis, in which the primary problem is poor ventricular function, neurohormonal activation, or inflammation, with no independent effect of atrial fibrillation on outcome.
  • IF Drugs Don’t work, Will Ablation? AF Ablation – eliminates confounding contributions of low efficacy and high toxicity associated with antiarrhythmic drug therapy – may better determine the desirability of maintaining sinus rhythm in patients with atrial fibrillation. – Clinical Trials are in progress comparing catheter ablation of atrial fibrillation to conventional antiarrhythmic drug therapy. – AF Ablation has yet to be proven to be better than rate control.
  • Rate versus Rhythm Control
  • Digoxin Described by William Withering, 1785 to treat rapid heart rate and CHF decreases conduction of electrical impulses through the AV node, making it a commonly used antiarrhythmic agent in controlling the heart rate during atrial fibrillation or atrial flutter. An increase of force of contraction via inhibition of the Na +/K+ ATPase pump
  • Quinidine- OLD school seen as too dangerous now A stereoisomer of quinine initially derived from the bark of the cinchona tree has been used for decades for AF.  Chinchona is an evergreen native to the mountainous areas of Central and South America. Quinine is the base flavor in most bitters and contributes the bitter essence to tonic water. Discovered by a Danish Merchant seaman with AF who took quinine for malaria prophylaxis during trips to India.  He noted his pulse was regular while in India but irregular at home. Chichonism describes tinnitus and hearing loss with quinidine excess.  Quinidine can cause thrombocytopenia, granulomatous hepatitis, myasthenia gravis, and torsades de pointes and for that reason is not used much today. Torsades can occur after the first dose.
  • Drugs used for atrial fib Flecanide Dofetilide Propafenone Sotolol Amiodarone Dronedarone
  • What is the Future of A Fib Advances in Anticoagulation New Drugs: Substantial resources are being invested in the development of new drugs that promise to be more efficacious and safer for use in patients with atrial fibrillation Advances in Ablation
  • Things that Havent worked in Atrial Fib Dronedarone: a novel antiarrhythmic drug with electrophysiological properties that are similar to those of amiodarone, but it does not contain iodine and thus does not cause iodine-related adverse reactions. In patients with severe heart failure and left ventricular systolic dysfunction, treatment with dronedarone was associated with increased early mortality related to the worsening of heart failure NEJM358: 2725-2727 June 19, 2008 Atrial Defibrillators – Convert the Atrial Fib, but not tolerated by patients.
  • Amiodarone side effects Skin toxicity Cataracts Lung fibrosis Liver damage Hypo/hyperthyroid
  • Indications for Catheter ablation of Atrial fibrillation
  • Left Atrial Circumferential Ablation VOM (1) PV isolation for trigger initiation of AF (2) Ablation of areas of potential reentry rotors/wavelets (3) Transect the vein of Marshall (4) Vagal denervation altering electrophysiologic substrate
  • Atrial Fibrillation Talk Goals Describe etiology of Atrial fibrillation Treatmemt Goals for Atrial Fibrillation – – Novel Anticoagulants Rate Control/ Rhythm Control Advances in Therapy for Atrial fibrillation
  • Questions Goals were to discuss– Etiology of Atrial fib – Treatment of Atrial fib Anticoagulation Anti arrhythmic therapy – Advances in therapy
  • Balloon Catheter Technology in AF Ablation HIFU (Highfrequency Ultrasound) : noncontact technique with tissue heating Cryoablation: tissue contact and freezing Laser (infrared): tissue contact and heating
  • Catheter ablation *Ablation strategies target the PVs and or PV antrum. *Complete electrical isolation should be the goal.
  • Image Integration and Image-Guided Mapping and Ablation 3-Dimensional Electroanatomical Mapping (EAM) systems are used to construct image of the left atrium This image is merged into a LA CT or MRI scan Using intracardiac ultrasound, the antrum of the pulmonary veins can be reliably determined The location and delivery of radiofrequency energy can be monitored and tracked with the 3-D EAM system
  • Common Lesion Sets used in AF Ablation
  • ICE IMAGES
  • NON-PULMONARY VEIN TRIGGERS OF AFIB