Atrial Fibrillation

ATRIAL FIB BRILLATIONNew Advances in Management Roy Sauberma MD FACC y an,

Murgatroyd F, et al.: Lancet 1993;341:1317-22

www.escardio.org/guidelines

Atrial Fibrillati can severely ion affect the live of patients, ff t th li es f ti t producing variou symptoms that usreduce the patien Quality of Life nt’s

Zimetbaum, et al.: PACE 1999;22(Part II):782 C

Jung, et al.: J Am Coll Cardiol 1999;33(2):104A

Wolf PA, et al.: Stroke 1991;22:983-8

Warfarin (CCoumadin)INR testing required (target = 2 3) 2-3) Daily d dosing Generic a available Dabigatran (Pradaxa) n No INR testi required ingTwice daily dosing (75 mg, 150 mg) g No generic available c

Stro oke D 110mg vs. D 150mg vs. D 110mg D 150mg warfar rin Warfarin Warfarin Annual Annual Annuaal RR RR P P rate t rate t rate t 95% CI % 95% CI %Stroke or 0.91 0.66systemic t i 1.5 15% 1.1 11% 1.7 1 7% 0.34 0 34 <0.001 <0 001Embolism 0.74-1.11 0.53-0.82 0.92 0 92 0.64 0 64Stroke 1.4 % 1.0 % 1.6 % 0.41 <0.001 0.74-1.13 0.51-0.81

Bleeding g D D D 110mg vs. D 150mg vs. Warfar rin 110mg 150mg Warfarin Warfarin Annual Annual Annuaal RR RR p p rate rate rate 95% CI 95% CI 0.91 0 91 0.78 <0.00Total 14.6% 16.4% 18.2% % 0.86- 0.002 0.74-0.83 1 0.97 0.80 0.93Major 2.7 % 3.1 % 3.4 % 0.003 0.31 0.69-0.93 0.81-1.07Life- 0.81 0.68 <0.00Threatening g 1.2 % 1.5 % 5 1.8 % 0.66 0.66- 0.04 4 0.55-0.83 8 1major 0.99Gastro- 1.10 1.50intestinal 1.1 % 1.5 % 1.0 % 0.43 <0.001 0.86 1.41 0.86-1.41 1.19 1.89 1.19-1.89MajorM j

FDA NEWS RELEASEFor Immediate Release: Oct. 19, 2010FDA approves Pradaxa to prevent str roke in people with atrial fibrillationThe U.S. Food and Drug Administration today approved Pra adaxa capsules (dabigatran etexilate) for the prevention ofstroke and blood clots in patients with abnormal heart rhyt thm (atrial fibrillation).

LAA OCCLUDERS A Investigational

J Am Coll Cardiol 2004:43;1201-8 o

AV NODAL ABLATION• Rapid, uncontrolled ven p , ntricular rates during AF g• Refractory or intolerant o antiarrhythmic therapy y of y y

AV Nodal Ablation al a

Pacemaker Required r

Subjective Benefits of AV Nodal Ablation 1.0 10 110 100 .90 90 .80 80 .70 70 PGWBMHIQ 70 .60 60 .50 p < 0.01 p < 0.01 50 .40 40 40 0 30 Pre Post Pre Post McMaster Health Index Questionnaire physical Psychological General Well-Being Index scores dimension scores before and after procedure. before and after procedure. High score = High score = better functional capacity. greater perception of health and well-being. Kay GN, et al.: Am J Cardiol 1988;62:741-4

Objective Benefits of AV Nodal Ablation f 70 55 mean 54 + 7 50 60 mean 45 40 + 5 mm) mean %) LVESD (m 50 meanLVEF (% 43 + 8 40 34 + 5 35 40 p < 0 001 0.001 30 p < 0 003 0.003 30 25 20 20 Before After Before After LVEF (%) LVESD (mm) Rodriguez LM, et al.: Am J Cardiol 1993;72:1137-41 m

p<0.01J Am Coll Cardiol 2003 Jul 2;42(1):30-2 l

5-8% of AF pa atients remain highly symp g y ymptomatic, ,require at least one ca ardioversion per year, despite antiarrhythm drug therapy !! mic Seidl K, et al.: J Am Coll Cardiol 1999;33(2):146A

2011 ACCF/AHA/HRS Focused Update on the Management ofPatients With Atrial Fibrillation (Updating the 2006 Guideline) nA Report of the Americ College of Cardiology canFoundation/American H Heart Association TaskForce on Practice Guidelines Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll

Ablation Therapy f Patients with bl i h y for i ih Paroxysmal Attrial Fibrillation Class I Catheter ablation performed in e experienced centers* is useful in maintaining sinus rhythm i sele t d patients with significantly i t i i i h th in lected ti t ith i ifi tl symptomatic, paroxysmal AF wh have failed treatment with an ho antiarrhythmic drug and have no y g ormal or mildly dilated left atria, y normal or mildly reduced LV funnction, and no severe pulmonary disease. (Level of Evidence: A)*Refers to pulmonary vein isolation with catheter ablation. An experienced center is defin as one performing more than 50 AF catheter ablation cases per year. Evidence-based nedtechnical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain adatabase detailing procedures; success and complications engage strategies for continu complications, uous quality improvement, and participate in registries and other efforts pooling data in improvementorder to develop optimal care algorithms . Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll

AF Tr riggersHaissaguerre, et al.: J Cardiova Electrophysiol 1996;7:1132-44 asc

AF Tr riggersHaissaguerre, et. al.: N E Engl J Med 1998;339:659-66

Nathan, et. al.: Circulation 1966;34;412-22 u

AF Tr riggersHaissaguerre, et. al.: N E Engl J Med 1998;339:659-66

Li ewire™ TC Live i Ablatio Catheters onDiagnostic Catheters Guiding Introducers Specialty Spiral Catheters Introducers Steerab Diagnostic ble Catheters C

Wide Area Circum mferential Ablation Oral et al.: Circulat tion 2003;108;2355-60

Procedural Success P d al SElimination of Pulmo onary Vein Potentials During A Ablation

Cryoballoo AblationC b ll on Abl ti

STOP AF TRIAL FSustained Treatment of Paroxysmal Atrial Fibrillati Trial ion

STOP AF TRIAL F• Palpitations decreased from 86% to 25% d• Fatigue decreased from 76% to 13% m• Rapid heartbeat decre eased from 66% to 16%• Diffi lt b thi decreased from 54% to 9% Difficulty breathing df t• Dizziness decreased fr rom 48% to 9%• Fainting decreased fro 4% to 1% om• Overall quality of life significantly improved

Hansen Robotic System b y

AF ABL LATION Benefits f Risks BleedingRestoration of sinus rhythm Stroke PneumothoraxRelief of AF-related symptoms AF related Pulmonary vein stenosis P l i t iElimination of antiarrhythmic Rx Diaphragmatic paralysis ulationLess need for long-term anticoagu Myocardial infarction Esophageal fistula Other atrial arrhythmias

AF remains a m major public h l h issue l health Increasin population at risk ng Significan morbidity & costs g nt yAnticoagulants reduce stroke risk s Warfarin Dabigatra anDrug therapy available for symptom relief a Rate cont agents trol Antiarrhy ythmic drugs y gCatheter-based ablative therapies have emerged d AV nodal ablation to control AF rate l Pulmonary vein isolation to prevent AF recurrence

Berkeley Heights y Mill lburn Bay yonne

Atrial Fibrillation

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