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“Ablating Asymptomatic AF”

“Ablating Asymptomatic AF”. Francis Marchlinski, MD Director Cardiac Electrophysiology University of Pennsylvania Health System Philadelphia, PA USA Francis.marchlinski@uphs.upenn.edu. Presenter Disclosure Information Within the past 12 months, Company Name: Relationship:

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“Ablating Asymptomatic AF”

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  1. “Ablating Asymptomatic AF” Francis Marchlinski, MD Director Cardiac Electrophysiology University of Pennsylvania Health System Philadelphia, PA USA Francis.marchlinski@uphs.upenn.edu

  2. Presenter Disclosure Information Within the past 12 months, Company Name:Relationship: Biosense Webster Sponsored Research/Scientific Advisory Panel/Lecture Honorarium Biotronik Lecture Honorarium Boston Scientific Sponsored Research/Lecture Honorarium Medtronic Scientific Advisory Board/ Lecture Honorarium/ Abbot/St. Jude Medical Sponsored Research /Lecture Honorarium/ Scientfic Advisory Board

  3. Ablating Asymptomatic AF“Change in Guidelines -2017” 2B Indication –with additional discussion required 2B: means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered – recommendation was based on expert opinion and limited observational data What data should you consider and/or discuss with patient? Calkins et al 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on ablation atrial fibrillation, Heart Rhythm, Vol 14, No 10, October 2017

  4. Asymptomatic AF “Scope of the Problem” • ~30% of patients enrolled in the Cardiovascular Health Study (1) • ~45% of patients in the Stroke Prevention in Atrial Fibrillation (SPAF-III) • had AF detected incidentally-ECG performed for an unrelated reason(2) 1)Furberg CD et al Am J Cardiol 1994;74:236–41; 2)Blackshear et al Mayo Clin Proc 1996;71:150–60. EurObservational Research ProgrammeAFib (EORP-AF) Pilot General Registry. Asymptomatic A fib - common~40%/Only 20% always asympt - associated with age, more comorbidities, and high thromboembolic risk. - Has higher 1- year mortality compared with symptomatic patients –Due to later recognition/less OAC use? Higher Mortality if Asymptomatic 1237/3119 pts (39.7%) Boriani G….. Lip G Am J Med (2015) 128, 509-518 Recent clinical experience – 8 of 30 new pts for A fib evaluation and possible catheter ablation (27%) with “asymptomatic” Afib.

  5. Ablating Asymptomatic AF“Is Afib Really Asymptomatic and Trouble Free?” • Start with low hanging fruit that can influence decision making • Is there worsening LV function?, New or worsening MR?

  6. Reversible CM after AF Ablation – AF and Low LV EF (48 pts) 57% (P < 0.001) 41% Improvement in All Normalization in 94% Ablation – Time 0 Post Ablation Frequent paroxysmal AF (34pts) or apparentrate control with persistent (14pts) AF From Gentlesk et al J CardiovascElectrophysiol 2007; 18(1):9-14.

  7. Functional Mitral Regurgitation Due to AF: Reversal with AF Ablation (Retrospective Cohort Study – 53 pts in each group) 53pts MR GROUP MR GROUP Only 24% remained mod/severe Post successful ablation No/minimal MR linked to • Greater  LA size • Greater  Annular dimension Gertz Z et al J Am CollCardiol. 2011 Sep 27;58(14):1474-81

  8. Ablating Asymptomatic AF“Is Afib Really Asymptomatic and Trouble Free?” • Low hanging fruit – • Worsening LV function? Worsening – New MR? • Exercise/Activity Intolerance? • Subtle Clues: • - Weight gain -↓↓ exercise level dated to onset of Afib • - Changes in behavior – Sexual interest/performance ↓↓, stopped playing sport, stopped walking when travel (Ask spouse for input) • Trial of cardioversion and assess symptoms/exercise tolerance – • - Recommended particularly if no CV in the past • Considerations:(How long in AF, LA size, anticoagulation, potential for bradycardia?) • If AF of any duration( >3mos) or early AF after previous CV – use antiarhythmic drug therapy before CV

  9. Ablating Asymptomatic AF“Symptoms Indirectly Related to Afib?” 2) Recognize extreme psychologic distress from having Afib in some patients? 3) No clear Afib symptoms but side effects with meds - Nightmares, sleep disturbances, - Fatigue, - Erectile dysfunction, - Reynaud's, - Lower extremity edema or constipation with calcium channel blockers, - Loss of exercise peak performance, - Decrease physical activity and weight gain

  10. Ablating Asymptomatic AF“Study Results Supporting Ablation” • 61 patients with asymptomatic long standing persistent AF - 36 AF free(59%) Improved QOL + Exercise Performance Mohanty S et al JCardiovascElectrophysiol,Vol.25,pp.1057-1064,October2014

  11. Ablating Asymptomatic AF“Study Results Supporting Ablation” • 66 patients Asymptomatic Persistent AF • AF – Only 23(35%)AF free Improved QOL (Propensity Matched Cohort) Asymptomatic and AF Free Symptomatic and AF Free Wu L et al JCE,Vol.27,pp.531-535, May 2016

  12. Asymptomatic AF Ablation “Does it Work as Well?(Controversy)” 54pts As effective in eliminating Afib in Asymp as Symp patients 66pts Not as effective in eliminating Afib in Asymp? G.B. Forleo et al.. Int J Cardiol 168 (2013) 3968–3970 Wu L et al JCE,Vol.27,pp.531-535, May 2016

  13. Asymptomatic AF Ablation“Can It Make Things Worse?” Pitfall – Make symptomatic Recurrences 25/61pts (Mohanty JCE 2014), 43/66pts (Wu JCE 2016) ~ 25% with LA Flutter (most with Symptoms) -17/61 pts(28%) (Mohanty JCE 2014) -16/66 pts(24%) (Wu et al JCE 2016) ? Avoid substrate based ablation to minimize chance of atrial flutter? Mohanty S et al JCE Vol.25,pp.1057-1064,October2014

  14. Ablating Asymptomatic AF“Special Consideration” • 49 y/o CHADS VASC = 0, with asymptomatic paroxysmal progressing to persistent AF and an increase in LA from 4.0 to 5.0 cm and LA volume increased to 39cc/m2. Reluctant to take life long anticoagulation. • 65 y/o with asymptomaticAfib - history of ulcerative colitis and occasional bloody stools, HTN – CHADVASC = 2. Reluctant to take OACs long term. • LAA Occlusion versus Afib ablation?

  15. Stroke Rate Stroke Rate After “ECG Successful” AF Ablation (4 Observational Studies) Off Anticoagulants AF increases risk of stroke – AF and not CHADS is primary driver of risk ***Oral et al Circulation. 2006;114:759-765 **Nadamanee et al JACC 2008; 51:843-849 †Themistoklakis et al JACC 2010 55 735-743 # Riley et al JCE 2014;25:591-96. *Gage BF, et al. JAMA. 2001;285(22):2864-2870

  16. Acute CVA – CHADSVASC= 0 withAfib Constant vigilance and monitoring for recurrence!! Regardless of CHADSVASC

  17. “Ablating Asymptomatic AF” • Check for worsening LV function or MR • Not all “asymptomatic” AF is truly asymptomatic • Also consider psych stress and med side effects • Consider restoring sinus rhythm to see if symptoms improvement • Recognize and discuss observational study results(optimistic) and pitfalls with ablation • - Sxs with recurrent flutter (15 -20% if extensive substrate ablation) • - Procedural risks • Consider trial of risk factor management • Ablation also may be option for special situations • - Low CHADSVASC with increasing LA size and no OAC desired • - Some bleeding risk and moderate stroke risk with Afib • (CHADS VASC 1-3) – no OAC desired

  18. Kalman J et al Circulation. 2017;136:490–499. DOI: 10.1161/ CIRCULATIONAHA.116.024926

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