Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRS Director, Cardiac...

Atrial Fibrillation: Update 2007

David L. Scher, FACP, FACC, FHRSDirector, Cardiac Electrophysiology

Pinnacle Health System and Associated Cardiologists, PCHarrisburg, PA

Clinical Associate Professor of MedicinePennsylvania State College of Medicine

October 13, 2007

Atrial fibrillation accounts for 1/3 of all

patient discharges with arrhythmia as principal diagnosis.

2% VF

Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

34% Atrial

Fibrillation

18% Unspecified

6% PSVT

6% PVCs

4% Atrial Flutter

9% SSS

8% Conduction

Disease3% SCD

10% VT

Classification

• Paroxysmal: recurrent (>2 episodes) that terminate spontaneously within seven days.

• Persistent: AF with duration greater than seven days, or requiring CV (drugs or electrical). Also includes “longstanding persistent AF” (continuous AF lasting greater than one year).

• Permanent: AF in which decision not to restore SR by any means is made.

Atrial Fibrillation: Cardiac Causes• Hypertensive heart disease

• Ischemic heart disease

• Valvular heart disease

– Rheumatic: mitral stenosis

– Non-rheumatic: aortic stenosis, mitral regurgitation

• Pericarditis

• Sinus node dysfunction

• Cardiomyopathy

– Hypertrophic

– Idiopathic dilated (? cause vs. effect)

• Post-coronary bypass surgery

Atrial Fibrillation: Non-Cardiac Causes

• Pulmonary

– COPD

– Pneumonia

– Pulmonary embolism

• Metabolic

– Thyroid disease: hyperthyroidism

– Electrolyte disorder

– Acidemia, sepsis, other hyperadrenergic states

• Toxic: alcohol (‘holiday heart’ syndrome)

AF: Pathophysiology

Wavelets

AF: Pathophysiology

Wyse and Gersch, Circulation, 2004;109:3089-3095

AF: Pathophysiology

Wyse and Gersch, Circulation, 2004;109:3089-3095

Why Treat AF?

Wyse and Gersch, Circulation, 2004;109:3089-3095

2006 ACC/AHA/ESC Practice Guidelines: Changes Since 2001 Guidelines

• Incorporation of major clinical trials.• Reorganized with emphasis on clinical patient

management.• Incorporation of catheter-based ablation technologies.• Drug therapy: those approved in N. America and

Europe• Emerging importance of angiotensin inhibition.• Prophylactic therapies.

JACC 2006, 48:e149-246

Rate Control vs. Rhythm Control

StudiesAFFIRM (2002)

RACE (2002)PAF (2000)

STAF (2003)HOT CAFE’ (2004)

No study demonstrated a difference in quality of life!

Rate Control vs. Rhythm Control

• However, judgment should be exercised in applying this lack of difference of QOL to individual patients!

• Definition of rate control: less than 100 bpm over at least 18 hr monitoring period, or less than 100% of maximum age-adjusted predicted exercise heart rate.

• Regardless of treatment strategy, antithrombotic therapy is to be continued in indicated patients!

Clinical Management

Clinical Management

Clinical Management

Clinical Management: Which AA Drug?

Catheter and Surgical Ablation of AF

Atrial Fibrillation Ablation: HRS/EHRA/ECAS Expert Consensus

Statement

• Electrophysiologic basis and rationale

• Patient Selection

• Methods

• Complications

• Appropriate follow-up and long-term management

Ablation: Electrophysiologic Basis

Traditional Theory: Wavelets

Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins

Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Mélèze Hocini, M.D.,

Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Philippe Le Métayer, M.D., and Jacques

Clémenty, M.D

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Volume 339:659-666

September 3, 1998     

Number 10

Embryology of the Pulmonary Veins

Pulmonary Veins

Catheter Ablation of AF: Different Approaches

Patient Selection• Symptomatic AF refractory or intolerant to at least

one Class 1 or class 3 antiarrhythmic drug.

• Only absolute contraindication: LA thrombus (TEE before ablation in pts. with persistent AF).

• Other considerations:– Success less likely in pts. with marked LA dilatation.– Higher complication rate in very elderly.– Pts.’ desire to discontinue warfarin is not an

appropriate sole indication for ablation.

Complications

• Cardiac tamponade• Pulmonary vein stenosis• Atrio-esophageal fistula• Phrenic nerve injury• Thromboembolism

Complications

• Air embolism• Post-procedural arrhythmias• Vascular complications• Acute coronary occlusion• Periesophageal vagal injury

Appropriate Follow-up and Long-Term Management: Areas of Consensus

• IV or LMW heparin bridging.

• Warfarin for at least 2 months in all patients.

• Decision re: warfarin after 2 months based on pt. risk factors NOT presence or absence of AF.

• Long-term warfarin for pts. With CHADS > 2.

Appropriate Follow-up and Long-Term Management: Areas of Consensus

• Repeat procedures: to be deferred for at least 3 months, if symptoms can be controlled with drugs.

• Definition of major complication: permanent injury, death, requiring intervention for treatment, or prolong or require hospitalization.

Appropriate Follow-up and Long-Term Management: Areas of Consensus

• Definition of success: freedom from AF/flutter/tachycardia is primary endpoint. Has varied: freedom for AF w/ and w/o sx, 90% reduction of AF burden, presence of AA drugs.

• Recurrence defined as AF/flutter/tachycardias documented lasting > 30 seconds (does not include early recurrence blanking period of 3 months).

• Early recurrence common and not failure: 35%, 40%, 45% at 15, 30, and 60 days respectively.

• Late recurrence (> 1 yr): 5-10%.

Appropriate Follow-up and Long-Term Management: Areas of Consensus

• Minimal monitoring: – office F/U 3 months post ablation and Q 6 mos. for 2

yrs.

– Event recorder monitoring for palpitations.

– 24-hour Holter monitoring at 3-6 mo. intervals for 1-2 yrs for clinical trials.

Literature Review: Non-randomized trials

• Single procedure success, %:– Paroxysmal AF: >60 (38-78)

– Persistent: <30 (22-45)

– Mixed: 16-84

• Multiple procedure success, %:– Paroxysmal: >70, (37-88)

– Persistent: >50 (37-88)

– Mixed: 31-80.

Literature Review: 5 Randomized trials

• 2005:70 pts randomized flecainide/sotalol or ablation:– recurrence= AF w/ or w/o sx.

– AA: 63%

– Abl: 13%

• 2006: (146 pts) Persistent AF CV vs. ablation:– Recurrence: freedom from AF/AFL w/o drugs.

– CV: 58%

– Abl: 74%

Literature Review: 5 Randomized trials

• 2006: (137 pts) Prospective: Role of abl as adjunctive Rx:– Recurrence: AA: 81%, ablation + AA: 45%

• 2006: (199 pts) Randomized, prospective: AA vs ablation:– Recurrence: AA: 78%, ablation: 14%

• 2006: (112 pts) AA vs ablation:– Recurrence: AA: 93%, ablation: 25%

– 63% of AA pts crossed over to ablation

Catheter Ablation of AF

J Cardiovasc Electrophysiol. 2006;17:1-6

Surgical Ablation of AF

• Concomitant to other open heart operations.

• Stand alone surgery for AF.

Surgical Ablation of AF: Concomitant to other open heart operations

• Rationale:

– AF is an independent predictor of late mortality.

– AF associated with higher periop mortality.

– Majority of pts with persistent AF before surgery remain unless treated at time of surgery.

Surgical Ablation of AF: Concomitant to Other Open Heart Operations

• Involves cryoablation, mocrowave, or RF ablation isolation of pulmonary veins and LA lesions (including line to MV-LA isthmus).

– Results: 76%success with LA isthmus lesions, 29% without (mean F/U 41 mos).

– LA appendage occlusion should be strongly considered.

– Results highly variable depending on energy source and completeness of ablation lines.

Stand-alone Surgical Ablation

Surgical Maze Procedure

Cox JL et al. Ann of Surgery 1996;224(3):267-75.

Cox MAZE III Procedure

Cox JL et al. Ann of Surgery 1996;224(3):267-75.

Bipolar clamp ablation

Gross Pathology

Atrial Appendage

Stand-alone Surgical Ablation of AF

Thromboembolic Risk: Pathophysiology

• Wyse and Gersch, Circulation, 2004;109:3089-3095

Thromboembolic Risk Stratification: Who Needs Anticoagulation?

Thromboembolic Risk Stratification: Who Needs Anticoagulation?

Thromboembolic Risk Stratification: Who Needs Anticoagulation?

Thromboembolic Risk Stratification: Who Needs Anticoagulation?

SUMMARY

• AF is the most common arrhythmia for which pts. are hospitalized.

• AF is associated with an icreased risk of morbidity and mortality.

• Rhythm control is not necessary in older pts. with minimal or absence of symptoms.

• AA drugs should be chosen based on side effect and proarrhythmic potential, not efficacy (except amio).

• Catheter and surgical ablation are effective in symptomatic pts. unresponsive to medical Rx.

• Antithrombotic therapy guidelines should be followed.