Samir rafla real life outcome of atrial fibrillation ablation-cardio alex 2014

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Samir Rafla- Real life outcome of atrial fibrillation ablation-CardioAlex 2014

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Samir rafla real life outcome of atrial fibrillation ablation-cardio alex 2014

  1. 1. Real life outcome of atrialReal life outcome of atrial fibrillation ablationfibrillation ablation Samir Rafla, FACC, FESC Professor of Cardiology Alexandria Univ.
  2. 2. 22 Methods and Results-—A structured electronic database search of the scientific literature was performed for studies describing outcomes at ≥3 years after AF ablation, with a mean follow-up of ≥ 24 months after the index procedure. The following data were extracted: (1) single-procedure success, (2) multiple-procedure success, and (3) requirement for repeat procedures. Data were extracted from 19 studies, including 6167 patients undergoing AF ablation.
  3. 3. Single procedure freedom from atrialSingle procedure freedom from atrial arrhythmia at long-term follow-up wasarrhythmia at long-term follow-up was 53.1%53.1% (95% CI 46.2% to 60.0%) overall, 54.1% (95% CI(95% CI 46.2% to 60.0%) overall, 54.1% (95% CI 44.4% to 63.4%) in paroxysmal AF, and 41.8%44.4% to 63.4%) in paroxysmal AF, and 41.8% (95% CI 25.2% to 60.5%) in non paroxysmal AF.(95% CI 25.2% to 60.5%) in non paroxysmal AF. Substantial heterogeneity (>50%) wasSubstantial heterogeneity (>50%) was noted for single-procedure outcomes. Withnoted for single-procedure outcomes. With multiple procedures,multiple procedures, the long-term successthe long-term success rate was 79.8%rate was 79.8% (95% CI 75.0% to 83.8%)(95% CI 75.0% to 83.8%) overall, with significant heterogeneity (>50%).Theoverall, with significant heterogeneity (>50%).The average number of procedures per patient wasaverage number of procedures per patient was 1.51 (95% CI 1.36 to 1.67).1.51 (95% CI 1.36 to 1.67). 33
  4. 4. ConclusionsConclusions-—Catheter ablation is-—Catheter ablation is an effective and durable long-terman effective and durable long-term therapeutic strategy for some AF patients.therapeutic strategy for some AF patients. Although significant heterogeneity is seenAlthough significant heterogeneity is seen with single procedures, long-term freedomwith single procedures, long-term freedom from atrial arrhythmia can be achieved infrom atrial arrhythmia can be achieved in some patients, but multiple proceduressome patients, but multiple procedures may be required.(J Am Heart Assoc.may be required.(J Am Heart Assoc. 2013;2:e0045492013;2:e004549 44
  5. 5. Single-Procedure Efficacy of CatheterSingle-Procedure Efficacy of Catheter Ablation Outcome dataAblation Outcome data Most studies provided single procedureMost studies provided single procedure success rates, defined as the percentage ofsuccess rates, defined as the percentage of patients free of atrial arrhythmia or notpatients free of atrial arrhythmia or not requiring a second procedure at 12 months.requiring a second procedure at 12 months. The pooled overall success rate wasThe pooled overall success rate was 64.2%64.2% (95% CI 57.5% to 70.3%). The pooled 12-month(95% CI 57.5% to 70.3%). The pooled 12-month success rate for the 11 studies reportingsuccess rate for the 11 studies reporting outcomes for PAF patients wasoutcomes for PAF patients was 66.6%66.6% (95% CI(95% CI 58.2% to 74.2%), and for the 6 studies58.2% to 74.2%), and for the 6 studies reporting outcomes for NPAF patients, it wasreporting outcomes for NPAF patients, it was 51.9%51.9% (95% CI 33.8% to 69.5%).(95% CI 33.8% to 69.5%). 55
  6. 6. Impact of Multiple ProceduresImpact of Multiple Procedures Thirteen studies provided outcome dataThirteen studies provided outcome data taking into consideration the impact oftaking into consideration the impact of multiple procedures. The overall multiplemultiple procedures. The overall multiple procedure long-term success rate wasprocedure long-term success rate was 79.8%79.8% (95% CI 75.0% to 83.8%) in 13 studies (Figure(95% CI 75.0% to 83.8%) in 13 studies (Figure 3). The overall was >50%, indicating3). The overall was >50%, indicating significant heterogeneity. The multiple-significant heterogeneity. The multiple- procedure long-term success in PAF wasprocedure long-term success in PAF was 79.0%79.0% in 8 studies (95% CI 67.6% to 87.1%),in 8 studies (95% CI 67.6% to 87.1%), and that in NPAF wasand that in NPAF was 77.8%77.8% in 4 studiesin 4 studies (95% CI 68.7% to 84.9%, P=0.9 versus PAF).(95% CI 68.7% to 84.9%, P=0.9 versus PAF). 66
  7. 7. Long-term Ablation EfficacyLong-term Ablation Efficacy Until very recently, few data have beenUntil very recently, few data have been available on AF ablation outcomes beyond 3available on AF ablation outcomes beyond 3 years after the index procedure. Both single-years after the index procedure. Both single- and multiple-procedure success ratesand multiple-procedure success rates showed relative stability at>3 years aftershowed relative stability at>3 years after index ablation. Including multiple proceduresindex ablation. Including multiple procedures 80% of patients in the included studies were80% of patients in the included studies were free of atrial arrhythmia at long-term follow-free of atrial arrhythmia at long-term follow- up.up. 77
  8. 8. Table. Complications of CatheterTable. Complications of Catheter Ablation in the Included StudiesAblation in the Included Studies 88
  9. 9. 99
  10. 10. 1010
  11. 11. 1111 Cryoballoon versus RF Ablation in Paroxysmal Atrial Fibrillation J Cardiovasc Electrophysiol. 2014;25(1):1-7 German Ablation Registry-Different Energy Sources in AF Ablation: Results Acute success rate was similar in both groups (97.5% in cryo vs 97.6% in RF; P = 0.81). Procedure times were similar, ablation and fluoroscopy times were higher in cryoballoon when compared to RF ablation. Overall complication rate was similar in cryo- (4.6%) and RF-ablation (4.6%; P = 1.0). Phrenic nerve palsy was more often in cryo versus RF ablation (2.1% in cryo vs 0.0% in RF; P < 0.001). Other complications were more common in RF compared to cryoablation (4.6% in RF vs 2.7% in cryo; P < 0.05).
  12. 12. ConclusionConclusion RF ablation is theRF ablation is the most widespread ablation method inmost widespread ablation method in Germany, but use of cryoballoon increasedGermany, but use of cryoballoon increased significantly. Procedure times were similar,significantly. Procedure times were similar, but ablation and fluoroscopy times werebut ablation and fluoroscopy times were longer in cryoballoon ablation. No significantlonger in cryoballoon ablation. No significant differences were found in terms of acutedifferences were found in terms of acute success and overall complication rate.success and overall complication rate. 1212
  13. 13. Catheter Ablation vs. AntiarrhythmicCatheter Ablation vs. Antiarrhythmic Drug Treatment of Persistent Atrial FibrillationDrug Treatment of Persistent Atrial Fibrillation Eur Heart J. 2014;35(8):501-507Eur Heart J. 2014;35(8):501-507 BackgroundBackground Catheter ablation (CA) is a highlyCatheter ablation (CA) is a highly effective therapy for the treatment of paroxysmaleffective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared withatrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). Noantiarrhythmic drug therapy (ADT). No randomized studies have compared the tworandomized studies have compared the two strategies in persistent AF. The presentstrategies in persistent AF. The present randomized trial aimed to compare therandomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistenteffectiveness of CA vs. ADT in treating persistent AF.AF. 1313
  14. 14. In total, 146 patients were includedIn total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT(aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or classgroup received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treatIII drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in theanalysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) inCA group and 21 of 48 patients (43.7%) in the ADT group were free of the primarythe ADT group were free of the primary endpoint (endpoint (PP = 0.002), implying an= 0.002), implying an absolute risk difference of 26.6% (95% CIabsolute risk difference of 26.6% (95% CI 10.0–43.3) in favour of CA.10.0–43.3) in favour of CA. 1414
  15. 15. The proportion of patients free ofThe proportion of patients free of any recurrence (>30 s) was higher in theany recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs.CA group than in the ADT group (60.2 vs. 29.2%;29.2%; PP < 0.001) and cardioversion was< 0.001) and cardioversion was less frequent (34.7 vs. 50%,less frequent (34.7 vs. 50%, respectively;respectively; PP = 0.018).= 0.018). ConclusionConclusion Catheter ablation is superiorCatheter ablation is superior to medical therapy for the maintenanceto medical therapy for the maintenance of sinus rhythm in patients withof sinus rhythm in patients with persistent AF at 12-month follow-up.persistent AF at 12-month follow-up. 1515
  16. 16. Pacing or Ablation: Which Is Better forPacing or Ablation: Which Is Better for Paroxysmal Atrial Fibrillation-RelatedParoxysmal Atrial Fibrillation-Related Tachycardia-Bradycardia Syndrome?Tachycardia-Bradycardia Syndrome? Pacing Clin Electrophysiol. 2014;37(4):403-411Pacing Clin Electrophysiol. 2014;37(4):403-411 The outcome of AF ablation in patients with paroxysmalThe outcome of AF ablation in patients with paroxysmal AF-related tachycardia-bradycardia syndrome wasAF-related tachycardia-bradycardia syndrome was compared the efficacy of catheter ablation withcompared the efficacy of catheter ablation with permanent pacing plus antiarrhythmic drugs (AADs).permanent pacing plus antiarrhythmic drugs (AADs). ConclusionsConclusions:: In patients with paroxysmal AF-relatedIn patients with paroxysmal AF-related tachycardia-bradycardia syndrome, AF ablation seemstachycardia-bradycardia syndrome, AF ablation seems to be superior to a strategy of pacing plus AAD.to be superior to a strategy of pacing plus AAD. Pacemaker implantation can be waived in the majority ofPacemaker implantation can be waived in the majority of patients after a successful ablation.patients after a successful ablation. 1616
  17. 17. Long-term outcome following successful pulmonaryLong-term outcome following successful pulmonary vein isolation: pattern and prediction of very latevein isolation: pattern and prediction of very late recurrence.recurrence. J Cardiovasc Electrophysiol.J Cardiovasc Electrophysiol. 2008 Jul;19(7):661-7 2008 Jul;19(7):661-7 RESULTS:RESULTS: During 28 +/- 12 months follow-up, 23 of 264 During 28 +/- 12 months follow-up, 23 of 264  (8.7%) patients had recurrence of AF. The actuarial (8.7%) patients had recurrence of AF. The actuarial  recurrence at 2 years post-ablation was 5.8% and recurrence at 2 years post-ablation was 5.8% and  increased to 25.5% at 5 years. Compared with long-term increased to 25.5% at 5 years. Compared with long-term  responders, more patients with late recurrence had responders, more patients with late recurrence had  hypertension and hyperlipidemia. Among 18 patients hypertension and hyperlipidemia. Among 18 patients  with recurrent AF necessitating repeat PVI, 15 (83%) with recurrent AF necessitating repeat PVI, 15 (83%)  required re-isolation of > 1 PV and 28 of 45 (58%) PVs required re-isolation of > 1 PV and 28 of 45 (58%) PVs  showed reconnection. All PVs were re-isolated and five showed reconnection. All PVs were re-isolated and five  (28%) patients had additional linear ablation. All 15 (28%) patients had additional linear ablation. All 15  patients became AF-free again.patients became AF-free again. 1717
  18. 18. Catheter ablation for paroxysmal andCatheter ablation for paroxysmal and persistent atrial fibrillation.persistent atrial fibrillation. Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2012 Apr 18;4:CD007101 2012 Apr 18;4:CD007101 Randomised controlled trials (RCTs) A total of 32 RCTs Randomised controlled trials (RCTs) A total of 32 RCTs  (3,560 patients) were included. There were no (3,560 patients) were included. There were no  differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65), differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65),  fatal and non-fatal embolic complication (RR 1.01, 95% fatal and non-fatal embolic complication (RR 1.01, 95%  CI 0.18 to 5.68) or death from thrombo-embolic events CI 0.18 to 5.68) or death from thrombo-embolic events  (RR 3.04, 95% CI 0.13 to 73.43).Comparisons of (RR 3.04, 95% CI 0.13 to 73.43).Comparisons of  different CAs; 25 RCTs compared CA of various kinds. different CAs; 25 RCTs compared CA of various kinds.  Circumferential pulmonary vein ablation was better than Circumferential pulmonary vein ablation was better than  segmental pulmonary vein ablation in improving segmental pulmonary vein ablation in improving  symptoms of AF (p<=0.01) and in reducing the symptoms of AF (p<=0.01) and in reducing the  recurrence of AF (p<0.01). recurrence of AF (p<0.01).  1818
  19. 19. Catheter ablation for atrial fibrillationCatheter ablation for atrial fibrillation. . J AmJ Am Coll CardiolColl Cardiol 2011; 57:160-166.2011; 57:160-166. Among 100 patients, 175 ablations were performed, with Among 100 patients, 175 ablations were performed, with  a median of two procedures performed per patient.  a median of two procedures performed per patient.   When researchers examined recurrences since the last When researchers examined recurrences since the last  ablation, the arrhythmia-free survival rate increased, with ablation, the arrhythmia-free survival rate increased, with  investigators reporting rates of investigators reporting rates of 87%, 81%, and 63% at 87%, 81%, and 63% at  one, two, and five yearsone, two, and five years. Overall, 77 patients were . Overall, 77 patients were  arrhythmia-free at one-year follow-up, and 19 of these arrhythmia-free at one-year follow-up, and 19 of these  patients presented with a later recurrence. The presence patients presented with a later recurrence. The presence  of valvular heart disease and nonischemic dilated of valvular heart disease and nonischemic dilated  cardiomyopathy were independent predictors of cardiomyopathy were independent predictors of  recurrent atrial fibrillation in multivariate analysis.recurrent atrial fibrillation in multivariate analysis. 1919
  20. 20. A recent worldwide survey reportedA recent worldwide survey reported 87458745 patients treated at 181 centres.patients treated at 181 centres. The numbers perThe numbers per year increased from 18 patients in 1995 to 5050year increased from 18 patients in 1995 to 5050 in 2002. The majority underwent segmentalin 2002. The majority underwent segmental pulmonary vein isolation,pulmonary vein isolation, 27.3%27.3% had more thanhad more than one procedure, and major complicationsone procedure, and major complications occurred inoccurred in 6.0%6.0%;; 52%52% became asymptomatic,became asymptomatic, and a further 23.9% were improved byand a further 23.9% were improved by antiarrhythmic drugs. Also of note is the fact thatantiarrhythmic drugs. Also of note is the fact that centres which had performed the mostcentres which had performed the most procedures tended to have the highest successprocedures tended to have the highest success rates.rates. Cappato RCappato R, Calkins H, Chen S-A, , Calkins H, Chen S-A, et al.et al. Worldwide survey  Worldwide survey  on the methods, efficacy, and safety of catheter ablation for on the methods, efficacy, and safety of catheter ablation for  human atrial fibrillation. Circulation 2005;111:1100–5human atrial fibrillation. Circulation 2005;111:1100–5 2020
  21. 21. A non-randomised study examining outcomeA non-randomised study examining outcome in 589 patients following catheter ablation forin 589 patients following catheter ablation for AF showed improved mortality, morbidity, andAF showed improved mortality, morbidity, and quality of life, compared to 582 medicallyquality of life, compared to 582 medically treated patients. Indeed, the overall survivaltreated patients. Indeed, the overall survival of ablated patients was no different to that ofof ablated patients was no different to that of the general population, matched for age andthe general population, matched for age and sex.sex. Pappone C, Rosanio S, Augello G,Pappone C, Rosanio S, Augello G, et al.et al. Mortality,Mortality, morbidity, and quality of life after circumferentialmorbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation:pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-outcomes from a controlled nonrandomized long- term study. J Am Coll Cardiol 2003;42:185–97term study. J Am Coll Cardiol 2003;42:185–97 2121
  22. 22. In-Hospital Complications Associated With CatheterIn-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United StatesAblation of Atrial Fibrillation in the United States Between 2000 and 2010.Between 2000 and 2010. Analysis of 93 801 Procedures. Analysis of 93 801 Procedures.  DeshmukhDeshmukh. Circulation.2013; 128: 2104-2112. Circulation.2013; 128: 2104-2112 The overall frequency of complications wasThe overall frequency of complications was 6.29%6.29% with combined cardiac complications (with combined cardiac complications (2.54%2.54%) being) being the most frequent. Cardiac complications werethe most frequent. Cardiac complications were followed by vascular complications (followed by vascular complications (1.53%1.53%),), respiratory complications (respiratory complications (1.3%1.3%), and neurological), and neurological complications (complications (1.02%1.02%). The in-hospital). The in-hospital mortality wasmortality was 0.46%0.46%. Annual operator (<25 procedures) and. Annual operator (<25 procedures) and hospital volume (<50 procedures) were significantlyhospital volume (<50 procedures) were significantly associated with adverse outcomes. There was aassociated with adverse outcomes. There was a small (nonsignificant) rise in overall complicationsmall (nonsignificant) rise in overall complication rates.rates. 2222
  23. 23. Trends inTrends in ComplicationsComplications for AFfor AF AblationsAblations Deshmukh.Deshmukh. Circulation.201Circulation.201 3; 128: 2104-3; 128: 2104- 21122112 2323
  24. 24. Complications of AF ablation:Complications of AF ablation: DeathDeath: Death is an infrequent complication of AF: Death is an infrequent complication of AF catheter ablation. peri-procedural death incidencecatheter ablation. peri-procedural death incidence observed in catheter ablation of AF does not differobserved in catheter ablation of AF does not differ from the incidence of peri-procedural death infrom the incidence of peri-procedural death in catheter ablation of supraventricular tachycardias.catheter ablation of supraventricular tachycardias. CausesCauses: the need of a transseptal puncture to reach: the need of a transseptal puncture to reach the left atrium and the PV ostia, the handling andthe left atrium and the PV ostia, the handling and manipulation of catheters in the left atrium and themanipulation of catheters in the left atrium and the association of radiofrequency-dependent lesions inassociation of radiofrequency-dependent lesions in the left atrium with very high levels ofthe left atrium with very high levels of anticoagulation.anticoagulation. 2424
  25. 25. Cardiac tamponadeCardiac tamponade (both acute(both acute and/or late) has demonstrated to be the mostand/or late) has demonstrated to be the most common fatal complication leading tocommon fatal complication leading to cardiac arrest during or after AF cathetercardiac arrest during or after AF catheter ablation, followed by development of atrio-ablation, followed by development of atrio- oesophageal fistulas. Ischaemic brain oroesophageal fistulas. Ischaemic brain or cardiac insults are the third most frequentcardiac insults are the third most frequent causes of death followed by extrapericardialcauses of death followed by extrapericardial bleedings related to subclavian or PVbleedings related to subclavian or PV perforation and by post-operative massiveperforation and by post-operative massive pneumonia refractory to antibiotics.pneumonia refractory to antibiotics. 2525
  26. 26. Atrio-oesophageal fistulaAtrio-oesophageal fistula is a veryis a very rare complication of AF catheter ablation.rare complication of AF catheter ablation. this complication is the most dreadful andthis complication is the most dreadful and lethal among all the others related to AFlethal among all the others related to AF catheter ablation.catheter ablation. Haemorrhagic ComplicationsHaemorrhagic Complications Haemorrhagic complications include majorHaemorrhagic complications include major and minor bleedings. Cardiac tamponadeand minor bleedings. Cardiac tamponade has to be considered a major bleeding and ishas to be considered a major bleeding and is by far the most common major complicationby far the most common major complication of AF catheter ablation.of AF catheter ablation. 2626
  27. 27. Thromboembolic EventsThromboembolic Events The introduction of open-irrigated cathetersThe introduction of open-irrigated catheters and the use of early and aggressiveand the use of early and aggressive heparinization have reduced significantlyheparinization have reduced significantly the risk of cerebrovascular events relatedthe risk of cerebrovascular events related to the procedure.to the procedure. Pulmonary Vein StenosisPulmonary Vein Stenosis: Occurring in 1–: Occurring in 1– 3% of cases.3% of cases. Phrenic nerve injuryPhrenic nerve injury occurred in 0.48% ofoccurred in 0.48% of cases.cases. 2727
  28. 28. Left atrial tachycardias or left atrial fluttersLeft atrial tachycardias or left atrial flutters are the most common 'electrophysiological'are the most common 'electrophysiological' complications of AF catheter ablation.complications of AF catheter ablation. Occurring in up toOccurring in up to 31%31% of patientsof patients undergoing this procedure, theseundergoing this procedure, these arrhythmias are often more symptomaticarrhythmias are often more symptomatic than AF itself because they are oftenthan AF itself because they are often associated with high regular ventricularassociated with high regular ventricular response.response. 2828
  29. 29. 2929 Schematic of common lesion sets employed in AF ablation
  30. 30. Figure . Strategies for Rhythm Control in Patients withFigure . Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AFParoxysmal and Persistent AF 3030
  31. 31. 3131 *Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). †Drugs are listed alphabetically. ‡Depending on patient preference when performed in experienced centers. §Not recommended with severe LVH (wall thickness >1.5 cm). ║Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. ¶Should be combined with AV nodal blocking agents.

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