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Audit of ablation procedures for AF

Audit of ablation procedures for AF. Barts and The London. AF burden. Framingham Lifetime risk of developing AF = 25% Mortality: SMR =1.9 ♀ 1.5 ♂ NHS audit 1% of budget spent on AF ↓↓Quality of life Symptoms of AF Side effects of medication.

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Audit of ablation procedures for AF

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  1. Audit of ablation procedures for AF Barts and The London

  2. AF burden • Framingham • Lifetime risk of developing AF = 25% • Mortality: SMR =1.9 ♀ 1.5 ♂ • NHS audit • 1% of budget spent on AF • ↓↓Quality of life • Symptoms of AF • Side effects of medication Benjamin, E. J. et al. "Impact of atrial fibrillation on the risk of death: the Framingham Heart Study." Circulation 98.10 (1998): 946-52. Stewart, S. et al. "Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK." Heart 90.3 (2004): 286-92

  3. Are effective treatments available? • Antiarrhythmic drugs • Toxicity: AFFIRM • No benefit over rate control • SR has a prognostic benefit • Rate control and anticoagulation • As good as AADs: • Prognosis • QOL • Ximelagatran

  4. Non pharmacological methods • Pacemaker • Pace to suppress triggers of AF • Multisite or biatrial pacing • Atrial defibrillators • Surgical ablation • Catheter ablation

  5. Mechanisms of AF

  6. Isolation/destruction of triggers: Target pulmonary vein isolation (PVI) Total PVI ± other triggers Modification of atrial substrate: Linear lesions in left atrium, right atrium or both Wide circumferential lesions around pulmonary veins Catheter maze Ablation strategies Left atrial maze and PVI

  7. Pulmonary vein isolation

  8. Linear ablation in the left atrium

  9. Catheter maze

  10. Standards from published data

  11. Worldwide survey of AF ablationCappato et al. ESC 2004 • Data from 777 centres • Number of cases • 18 in 1995, 5050 in 2002 • Median of 37.5 cases per centre (range 1-600) • Commonest procedure • 1995-97 Right atrial maze • 1998-99 Target PVI • 2000-02 Electrical disconnection of all PVs • Outcomes • 8745 pts in 90 centres • 27.3% >1 procedure • 76% asymptomatic (24% on antiarrhythmic drugs) • 6% major complication rate

  12. St Bartholomew’s data • PATS database (EP and EP2) • Research database • Catheter maze study • Coarse AF study • Patient letters • DMS/EPR viewer • Telephone patients

  13. Total number of procedures 100 procedures in 73 patients

  14. Increasing number of procedures

  15. Patients N=73 50±8 years 58M 15F Type of AF: Cardiac diagnosis:

  16. Outcomes: improvement in symptoms?

  17. Outcomes: maintenance of sinus rhythm?

  18. Need for antiarrhythmic drugs?

  19. Need for repeat procedures? Number of procedures per patient:

  20. Success of 1st procedure

  21. Procedure times 281±120 49±25

  22. Major n=4 (4.5%) 2 Tamponade 1 Stroke 1 Severe PV stenosis Up to June 03 (11.4%) Since July 03 (0%) Minor n=7 (8.0%) 2 transient ST elevation 2 mild PV stenosis 1 tip of active fix pacing wire in RA 2 haematoma Complications

  23. Catheter maze study • Baseline characteristics: • 23 patients (19M 4F) • 49 ± 9 years • AF duration 4 ± 3 years(11 ± 9 months continuously) • 2.7 ± 1.7 DCCV • 3.3 ± 1 antiarrhythmic drugs • LA diameter 4.9 ± 0.9 cm • Mean follow up 10±7 months

  24. Catheter maze outcome Index Catheter Maze N=23 9 14 9 + 2* 3 AF or AFL recurrence 4 1 death fromunrelated cause 2 Repeat ablation 4 1 2nd or 3rdAF or AFL recurrence Permanent AF accepted N=3 8 Medium term Sinus rhythm N=17 (77%) * In AF awaiting further treatment N=2

  25. Results: symptoms and QOL Modified Karolinska (0-140) *P < 0.05 AF or AFL SR 58 ± 29 - Baseline 6 weekschange vs baseline -6 ± 37 -34 ± 24* 6 months change vs 6 weeks +14 ± 1.4 -6 ± 7

  26. Surgical Maze – BRACUS stidy • Bipolar Radiofrequency Ablation for Chronic atrial fibrillation in patients Undergoing mitral valve Surgery

  27. Conclusions • Clinical need for improved pharmacological or non pharmacological treatments for AF • AF ablation at St Bartholomew’s is effective and at a level with published data • Low but important complication rate

  28. St Bartholomew’s as a lead national centre for AF ablation • Increasing number of cases • Prospective symptom, QOL and rhythm collection • Publishing and presenting our data • Research • Catheter Maze • Coarse AF • BRACUS • Training • Centre of excellence for industry • Ensite NavX 4.0 and 5.0 • Digital Image fusion

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