1. ATRIAL FIB
BRILLATION
New Advances in Management
Roy Sauberma MD FACC
y an,

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

6. www.escardio.org/guidelines

15. www.escardio.org/guidelines

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

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

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

20. www.escardio.org/guidelines

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

24. www.escardio.org/guidelines

25. www.escardio.org/guidelines

26. www.escardio.org/guidelines

27. www.escardio.org/guidelines

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

31. 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 0.66
systemic
t i 1.5
15% 1.1
11% 1.7
1 7% 0.34
0 34 <0.001
<0 001
Embolism 0.74-1.11 0.53-0.82
0.92
0 92 0.64
0 64
Stroke 1.4 % 1.0 % 1.6 % 0.41 <0.001
0.74-1.13 0.51-0.81

32. 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 <0.00
Total 14.6% 16.4% 18.2%
% 0.86- 0.002
0.74-0.83 1
0.97
0.80 0.93
Major 2.7 % 3.1 % 3.4 % 0.003 0.31
0.69-0.93 0.81-1.07
Life- 0.81
0.68 <0.00
Threatening
g 1.2 % 1.5 %
5 1.8 % 0.66
0.66- 0.04
4
0.55-0.83
8 1
major 0.99
Gastro-
1.10 1.50
intestinal 1.1 % 1.5 % 1.0 % 0.43 <0.001
0.86 1.41
0.86-1.41 1.19 1.89
1.19-1.89
Major
M j

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

34. LAA OCCLUDERS
A
Investigational

36. www.escardio.org/guidelines

38. www.escardio.org/guidelines

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

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

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

46. AV Nodal Ablation
al
a

47. Pacemaker Required
r

48. Subjective Benefits of AV Nodal Ablation
1.0
10 110
100
.90
90
.80
80
.70
70
PGWB
MHIQ
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

49. Objective Benefits of AV Nodal Ablation
f
70 55
mean
54 + 7 50
60 mean
45 40 + 5
mm)
mean
%)
LVESD (m
50 mean
LVEF (%
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

52. Amio

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

54. 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

55. www.escardio.org/guidelines

56. 2011 ACCF/AHA/HRS Focused Update on the Management of
Patients With Atrial Fibrillation (Updating the 2006 Guideline)
n
A Report of the Americ College of Cardiology
can
Foundation/American H Heart Association Task
Force on Practice Guidelines
Wann LS et al.: J Am C Cardiol 2011;57:223-42
Coll

57. 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
ned
technical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain a
database detailing procedures; success and complications engage strategies for continu
complications, uous quality improvement, and participate in registries and other efforts pooling data in
improvement
order to develop optimal care algorithms .
Wann LS et al.: J Am C Cardiol 2011;57:223-42
Coll

58. 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
ned
technical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain a
database detailing procedures; success and complications engage strategies for continu
complications, uous quality improvement, and participate in registries and other efforts pooling data in
improvement
order to develop optimal care algorithms .
Wann LS et al.: J Am C Cardiol 2011;57:223-42
Coll

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

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

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

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

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

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

71. Procedural Success
P d al S
Elimination of Pulmo
onary Vein Potentials
During A
Ablation

74. Cryoballoo Ablation
C b ll on Abl ti

76. Cryoballoo Ablation
C b ll on Abl ti

81. STOP AF TRIAL
F
Sustained Treatment of Paroxysmal Atrial
Fibrillati Trial
ion

83. 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

84. Hansen Robotic System
b y

85. Hansen Robotic System
b y

89. AF ABL
LATION
Benefits
f Risks
Bleeding
Restoration of sinus rhythm Stroke
Pneumothorax
Relief of AF-related symptoms
AF related Pulmonary vein stenosis
P l i t i
Elimination of antiarrhythmic Rx Diaphragmatic paralysis
ulation
Less need for long-term anticoagu Myocardial infarction
Esophageal fistula
Other atrial arrhythmias

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

91. Berkeley Heights
y
Mill
lburn
Bay
yonne