AFIB SUMMIT 2015

1. Niraj Sharma, MD
• Electrophysiologist at
CardioVascular Group/Gwinnett
Medical Group
• Board Certified in Internal
Medicine, Cardiovascular
Diseases, and Electrophysiology
• Special interests include treating
patients with abnormal heart
rhythms, and ablation of
arrhythmias, including atrial
fibrillation.
Medical School:
Medical College Jabalpur
Residency:
Brown University
Fellowship:
Univ. of Texas
Southwestern Medical
Center

2. Niraj Sharma MD FACC FHRS
Gwinnett Health system

3. You see a patient in the hospital and determine she
needs warfarin. She does not want to take “rat poison”
and asks you how effective it is.
You quote warfarin efficacy (based on meta-trial data)
as:
A. 65% effective in ischemic stroke reduction
B. 80% effective
C. 90%
D. 55%

4. A) 65%

5. 45 year old female hiker with symptomatic (palpitation)
pAF has episodes lasting 3 days at a time. She has no
other medical history. Based on the CHADSVASC score
you will:
A. AC with warfarin
B. AC with Novel AC
C. No AC
D. Aspirin

6. C) No AC # 3
CHADSVASC score of 0 (female by itself is 0)

8. 60 year old male with asymptomatic permanent AF, with
diabetes. Based on CHADSVASC score you would:
A. AC with either Warfarin or NOAC
B. Aspirin
C. No AC
D. Any of the above

9. D) current guidelines (CHADSVASC 1, if female than
2)….USA (AC in Europe)
More recent evidence suggests # 1 (AC) per Lip or #3 as
per Friberg

10. Relationship of stroke risk and AF duration is:
A. Linear progression
B. Sigmoidal risk
C. Log-rhythmic
D. Stroke risk not assessed by duration

11. D) No relation
 Assessment of stroke risk does not take into account
duration
 This is different if DCCV being planned

12. 78 year old male with DM, HTN, prior CVA presents to
the ER at 11pm with new onset AF (started at 9pm while
watching dancing with the stars) with RVR and has
exertional SOB. Exam apart from AF, is unremarkable.
You would:
A. DCCV: because AF is <48 hours and the pt is
symptomatic
B. TEE and then DCCV
C. Rate control first, start AC and DCCV in 3-4 weeks
D. Call Cardiology

13. C) Rate control first, start AC and DCCV in 3-4 weeks
 CHADSVASC score does not have a role in evaluation
stroke risk in patients undergoing DCCV
 Caution while assessing 48 hour window
 Symptomatic AF tip of iceberg

14. 76 year old female with confirmed “mildly” symptomatic
AF and CHADSVASC score of 5 (female, HTN, DM, age)
presents to your office. She is currently in AF and her
vitals are: BP 148/88 P: irreg 90/min, other exam is
unremarkable. The best option is:
A. Start AC and initiate AAD treatment to reduce
episodes of AF and keep her in SR
B. Start AC
C. Start AC and get 24 hr Holter for VR control
D. AC for 3 weeks and DCCV and reassess symptoms

15. D) AC for 3 weeks and DCCV and reassess symptoms
AFFIRM

16. Dabigatran should NOT be used with which AAD?
A. Dronedarone
B. Flecanide
C. Sotalol
D. Dofetalide
E. 1 and 4
F. 1, 3 and 4
G. 2 and 4

17. ?
 Combination CI in Europe
 Combination of Dabigatran and Dronedarone
increased blood levels of Dabigatran and increases risk
of bleeding

18. 84 year old male with long standing persistent AF, DM,
HTN, CABG, MV repair and ESRD on HD.
The choice of AC is:
A. Apixaban
B. Rivaroxaban
C. Warfarin
D. Dabigatran

19. C) Warfarin
MV repair= Valvular AF

20. 28 year old male with AF and incidental diagnosis of
hypertrophic CMP on Echo done at PCP’s office for a
murmur. He is referred to you for risk assessment. You
would recommend:
A. No AC CHADSVASC score of 0
B. Warfarin
C. Apixaban
D. ASA
E. B or C

21. E) B or C
 HOCM is = CHADSVASC of 2
 Not considered “Valvular” AF

22.  Most common sustained rhythm problem
 Major disease with 2.6million people in 2010 and
projected be 12.5million in 2050
 Mortality rate with AF as primary or secondary
diagnosis increasing over the last 2 decades
 Morbidity a major concern: 15-20% of ischemic
strokes
 Major economic burden to the patient as well as
Healthcare

23.  Most common sustained rhythm problem
 Major disease with 2.6million people in 2010 and
projected be 12.5million in 2050
 Mortality rate with AF as primary or secondary
diagnosis increasing over the last 2 decades
 Morbidity a major concern: 15-20% of ischemic
strokes
 Major economic burden to the patient as well as
Healthcare

24. EPIDEMIOLOGY
• The most prevalent
sustained rhythm disorder
• Accounts for 1/3 of
hospitalisations due to
cardiac rhythm
disturbances
• Estimated prevalence in
USA 2.6 and worldwide 5.5
million
Arrhythmia-related hospitalisations
in the US
Atrial flutter 4%
Paroxysmal
supraventricular
tachycardia 6%
Atrial
fibrillation 34%
Ventricular
fibrillation 2%
Ventricular
tachycardia 10%
Miscellaneous 21%
Conduction
abnormalities 8%
Sick sinus
syndrome 9%
Premature
beats 6%

25.  AFib is responsible for a 5-fold increase in the risk of ischemic stroke
Wolf PA, et al. Stroke (1991) 22: 983
Go AS, et al. JAMA (2001) 285: 2370
Friberg J, et al. Am J Cardiol (2004) 94: 889
12
0
2
8
4
41 53 2 41 53
Cumulativestrokeincidence(%)
Women AFib+
Women AFib-
Men AFib+
Men AFib-
Years of follow-up

26.  Men 1.5x more then women
 Less common in AA
 12% 75-84: 1% <60yrs
 Tall (increase atrial size)/Obese (DM,OSA, HTN,
Systolic as well as diastolic dysfunction)
 Genetic rare
 Athletic lifestyle (high vagal tone)
 Cigarette smoking/Alcohol abuse

28. 1. Paroxysmal AF- episode that spontaneously
terminates in 7 days (~40% terminate in 24
hours)- minimal atrial scar most amenable to
ablation i.e. stops by itself
2. Persistent AF- episode that lasts >7 days or
requires cardioversion i.e. requires intervention
3. Permanent AF- fails to terminate with
cardioversion or terminates and relapses within
24 hours- most amount of atrial scar least
amenable to AAD or ablation i.e. end stage

30.  ACC/AHA/HRS: Rheumatic MV disease, prosthetic
valve or repair
 ACCP: MS, prosthetic valve
 ESC: Rheumatic valve disease, prosthetic valve
 Trial definitions:

33. CircRes.2014;114:1453-1468

34. CircRes.2014;114:1453-1468

36. Knowing the risk of stoke is essentially similar in AF and
in Atrial flutter, what would you prefer to have?
A. AF
B. Atrial flutter

37. B) Atrial flutter

39. 1. Single large reentrant circuit
in the RA
2. Difficult to rate control and
usually not paroxysmal
3. Ablation first line of
treatment
4. Ablation success >90-95%
1. Minimal risk for ablation
2. AC can be stopped after
ablation if no associated AF
1. Multiple small foci in and
around Pulmonary veins
2. Starts off as paroxysmal; easier
to rate control
3. Ablation if AAD fail
4. Ablation success 70-80% for
paroxysmal 60% for all
1. Can have serious
complications
2. AC continued after ablation if
risk factor ≥2

41. Cardioversion
• Pharmacological
• Electrical
Drugs to prevent Afib (tomorrow)
• Antiarrhythmic drugs
Drugs to control ventricular rate (tomorrow)
Drugs to reduce thromboembolic risk (Dr Gangasani)
Non-pharmacological options
• Electrical devices (implantable pacemaker and defibrillator)
• AV node ablation and pacemaker implantation (ablate & pace)
• Catheter ablation/Hybrid ablation (Dr Harvey)
• Surgery (Maze, mini-Maze) (Dr Harvey)
• LAA closure devices: Lariat, Watchman (Dr Unterman)

42. When and Why Acutely Cardiovert?

43. AF causes changes in atrial electrophysiology
that promote AF maintenance
Wijffels Circulation 1995; 92: 1954-68

44. In the ER you are consulted for new onset AF, started last
night, with IV diltiazem controlled VR and now
asymptomatic. The ER doc wants to DCCV and send
home. AC is started. You would:
A. Agree with her
B. ED obs and DCCV in am
C. TEE and DCCV in ER

46.  # 2

47. Danias J Am Coll Cardiol. 1998;31:588-92
• 356 pts with AF < 72 h
• Symptoms of < 24 h was only independent predictor of
spontaneous conversion (OR: 1.8, p < 0.0001)
< 24 h
24 - 72 h
Total
292
64
356
73%
45%
68%
AF duration n Conversion

48. Cardioversion of atrial flutter and fibrillation after
ibutilide infusion
Stambler Circulation. 1996;94:1613-1621

50. Zaqqa AJC 2000

51. Oral NEJM 1999;340:1849-54
100 consecutive patients
l 50 assigned conventional DC
l 50 pretreated with 1 mg
ibutilide
0
10
20
30
40
50
60
70
80
90
100
No ibutilide Ibutilide
Cardioversionsuccess(%)

53. Cardioversion
• Pharmacological
• Electrical
Drugs to prevent AFib
• Antiarrhythmic drugs
Drugs to control ventricular rate
Drugs to reduce thromboembolic risk
Non-pharmacological options
• AV node ablation and pacemaker implantation (ablate & pace)
• Catheter ablation/Hybrid ablation
• Surgery (Maze, mini-Maze)

55.  Age = 69.7 ± 9.0 yrs
 39% female
 > 2 days of AF in 69%
 CHF class > II in 9%
 Symptomatic AF in 88%

58. ACC/AHA/HRS Guidelines

59. Theoretically, rhythm control should have advantages over rate control,
yet a trend toward lower mortality was observed in the rate-control arm
of the AFFIRM study and did not differ in the other trials from the
outcome with the rhythm control strategy. This might suggest that
attempts to restore sinus rhythm with presently available
antiarrhythmic drugs are obsolete. The RACE and AFFIRM trials did
not address AF in younger, symptomatic patients with little underlying
heart disease, in whom restoration of sinus rhythm by cardioversion
antiarrhythmic drugs or non-pharmacological interventions still must
be considered a useful therapeutic approach. One may conclude from
these studies that rate control is a reasonable strategy in elderly
patients with minimal symptoms related to AF. An effective method for
maintaining sinus rhythm with fewer side effects would address a
presently unmet need.
ACC/AHA/HRS Guidelines

60. Maze reproduction Schwarz 1994
Right atrial linear lesions Haïssaguerre 1994
Right and left atrial linear lesions Haïssaguerre 1996
PV foci ablation
Jaïs / Haïssaguerre
1997/8
Ostial PV isolation Haïssaguerre 2000
Circumferential PV ablation Pappone 2000
Ablation of non-PV foci Lin 2003
Antral PV ablation Maroucche / Natale 2004
Double Lasso technique Ouyang / Kuck 2004
CFAE sites ablation Nademanee 2004
Ostial or circumferential or antral PV
ablation plus extra lines (mitral isthmus,
posterior wall, roof)
Jaïs / Hocini 2004/5
Circumferential PV ablation with vagal
denervation
Pappone 2004
Technique Publication date

61. Linear 443 75% 26% 33% 55%
Focal 508 81% 35% 54% 71%
Isolation 2,187 83% 36% 62% 75%
Circumferential
(all)
15,455 68% 37% 64% 74%
Circumferential
(LACA, WACA)
2,449 65% 37% 59% 72%
Circumferential
(PVAI)
11,132 68% 42% 67% 76%
Substrate ablation
(CFAE)
559 51% 49% 75% 87%
TOTAL 23,626 61% 55% 63% 75%
Patients
Paroxysma
l AF 6-month cure 6-months OKAblation method SHD
Fisher JD, et al. PACE (2006) 29: 523
Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the
absence of AAD.
OK means improvement (fewer episodes, no episodes with previously ineffective AAD).
SHD indicates structural heart disease.

62.  Total success rate: 76%
 Of 8745 patients:
 27.3% required 1 procedure
 52.0% asymptomatic without drugs
 23.9% asymptomatic with an AAD within <1 yr
 Outcome may vary between centres
Cappato R, et al. Circulation (2005) 111: 1100

63. RF ablation vs AAD as first-line treatment for AFib
• Wazni OM et al. JAMA (2005) 293: 2634-2640
Catheter ablation in drug-refractory AFib
• Stabile G et al. Eur Heart J (2006) 27: 216-221
Circumferential PV ablation for chronic AFib
• Oral H et al. N Engl J Med (2006) 354: 934-941

64. Oral H, et al. N Engl J Med (2006) 354: 9
Sinusrhythm(%)
12
0
20
60
100
80
40
Months
1110987654321
Circumferential
pulmonary-vein ablation
Control
Amiodarone & cardioversion (n=69) vs. amiodarone &
cardioversion plus PV ablation (n=77)

65. Transient ischaemic
attack
4 0.4 0 - 3
Permanent stroke 1 0.1 0 - 1
Severe PV stenosis
(>70%, symptomatic)
3 0.3 0 - 3
Moderate PV stenosis
(40-70%, asymptomatic)
13 1.3 0 - 5
Tamponade / perforation 5 0.5 0 - 3
Severe vascular access
complication
3 0.3 0 - 4
Events
(n)
Range in studies
(%)
Rate
(%)Complication
Major complications with pulmonary vein ablation
in 1039 patients (6 series)
Verma A & Natale A Circulation (2005) 112: 1214

66. 118 patients with symptomatic,
drug-refractory AFib
32 weeks
1.52 ± 0.71 ablation procedures
Catheter ablationPharmacological treatment
Weerasooriya R, et al. Pacing Clin Electrophysiol (2003) 26: 292
€4715 followed by
€445/year
€1590/year
After 5 years, the cost of RF ablation was below that of medical
management and further diverged thereafter

67. Clinical visits per year 7.4 (2.5) 1.1 (0.6)
Emergency room visits per
year
1.7 (0.9) 0.03 (0.17)
Hospitalization days per year 1.6 (0.8) 0 (0)
Healthcare costs per year $1920 (889) $87 (68)
No ablation Catheter ablation
Goldberg A, et al. J Interv Card Electrophysiol (2003) 8: 59
Although the initial cost of ablation is high, after ablation,
utilization of healthcare resources is significantly reduced

68. Recurrent
Paroxysmal AF
Minimal or
no symptoms
Disabling symptoms
in AF
Anticoagulation and rate
control as needed
Anticoagulation and rate
control as needed
No drug for prevention
of AF
AAD therapy
AF ablation if AAD
treatment fails
ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation