AF in Patients with Heart Failure
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AF in Patients with Heart Failure Role of AVN Ablation and CRT. Win K. Shen, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Cardiovascular Diseases Mayo Clinic Arizona ACC Florida, 2014. DISCLOSURE. Relevant Financial Relationship(s) None Off Label Usage None.

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AF in Patients with Heart Failure Role of AVN Ablation and CRT

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Af in patients with heart failure role of avn ablation and crt

AF in Patients with Heart Failure

Role of AVN Ablation and CRT

Win K. Shen, MD

Professor of Medicine

Mayo Clinic College of Medicine

Chair, Cardiovascular Diseases

Mayo Clinic Arizona

ACC Florida, 2014


Disclosure

DISCLOSURE

Relevant Financial Relationship(s)

None

Off Label Usage

None


Objectives atrial fibrillation and heart failure

ObjectivesAtrial Fibrillation and Heart Failure

  • Cyclical Relationship: Mechanisms

    • AF promotes HF

    • HF promotes AF

  • A Case Study

    • Indications for CRT

    • What should be the minimum % of pacing?

    • When to ablate the AVN?

  • A review of guidelines and consensus


Afib and chf temporal relations and mortality framingham study

Development of CHF in Pt with AFib

Cumulative incidence of CHF

Years

Impact of incident CHF on mortality (RR+CI)

Impact of incident AFib on mortality

Development of AFib in Pt with CHF

Men

Men

Women

Women

2.7(1.9-3.7)

1.6(1.2-2.1)

3.1(2.2-4.2)

2.7(2.0-3.6)

Cumulative incidence of AF

Years

AFib and CHF – Temporal Relations and MortalityFramingham Study

Benjamin: Circ, 2003

CP1119361-1


Atrial fibrillation and chf

Atrial Fibrillation and CHF

AFCHF

  • Loss of atrial contraction

  • Impaired ventricular filling

  • High heart rates

A vicious

cycle

Atrial

fibrillation

Neurohormonal activation

Sympathetic stimulation

Use of negative inotropic drugs

¯ EF

¯ perfusion

CHF AF

  • Atrial dilatation

  • Stretch receptor activation

  • Neuro-humoral modulation

  • Signal transduction/bioenergetics

  • Electropysiologic remodeling

  • Fibrosis

CHF

Triggered

activity

Refactoriness

Conduction

Automaticity

CP1110819-1


Af in patients with heart failure role of avn ablation and crt

71 year-old man has mixed CM for 2-3 years. He has permanent AF. Despite medical therapy, he has SOB walking 2-3 blocks and worse at higher altitude. Most recent EF was 28%, LVEDD 59 mm. He has been treated with carvedilol, losartan, lasix, simvastatin, ASA, warfarin. EKG is shown, QRSD 150 msec.

Case Study


Case study

Case Study

What would you recommend?

CRT is indicated (I)

CRT can be useful (IIa)

CRT may be reasonable (IIb)

CRT is not recommended (III)


Case study1

Case Study

If you did implant a CRT, would you recommend AVN ablation?

Yes

No


Case study2

Case Study

If you did not recommend AVN ablation, what would be the desired % of pacing?

> 50%

> 70%

> 90%

~ 100%


Af in patients with heart failure role of avn ablation and crt

CP1313975-1


Af in patients with heart failure role of avn ablation and crt

Recommendations for CRT in Patients With Systolic Heart Failure

AHA/ACC/HRS 2012


Cardiac resynchronization therapy permanent afib

Cardiac Resynchronization Therapy Permanent AFib

Brignole et al: EHJ 34:2281, 2013


Case study3

Case Study

What would you recommend?

CRT is indicated (I)

CRT can be useful (IIa)

CRT may be reasonable (IIb)

CRT is not recommended (III)


Variable bv pacing in af

Variable BV Pacing in AF

Conducted AF Response

(BV)

VSR/VTR

Pseudo Fusion


Six studies reporting outcome data for af patients undergoing crt for hf

Six Studies Reporting Outcome Datafor AF Patients Undergoing CRT for HF

*Represents mean age of CRT-AF patients as a group; †24% lost to follow-up

Ganesan et al: J Am Coll Cardiol 2012;59:719–26


Af in patients with heart failure role of avn ablation and crt

Mean Difference in NYHA Functional Class for CRT-AF Patients Undergoing AVNA vs Medical Therapy with Rate-Controlling Drugs

DifferenceDifference in meansStudy namein meansPand 95% CI

Molhoek 2004-0.1000.572

Ferreira 2008-0.5000.000

Dong 2010-0.3000.009

-0.3390.002

-20

-10

0

10

20

Favors AVNA+

Favors AVNA-

Ganesan et al: J Am Coll Cardiol 2012;59:719–26


Case study4

Case Study

If you did not recommend AVN ablation, what would be the desired % of pacing?

> 50%

> 70%

> 90%

~ 100%


Case study crt d implanted 05 22 12

Case Study CRT-D Implanted (05/22/12)


Case study post implantation ekg 5 22 12 qrsd 138 msec

Case Study Post Implantation EKG (5/22/12)QRSD 138 msec


Case study follow up 10 22 13

Case Study Follow Up (10/22/13)

98% BV pacing

QRSD 138 msec, LVEDD 55 mm

EF 42%, symptoms improved from II to 1-II


Af in patients with heart failure role of avn ablation and crt

Indication for AVJ Ablation in Patients With Symptomatic Permanent AFib and OptimalPharmacological Therapy

Heart Failure, NYHA class III–IV and EF <35%

Reduced EF and

uncontrollable HR, any QRS

QRS ≥120 ms

QRS <120 ms

CRT

Adequate

rate control

Inadequate

rate control

Incomplete

BiV pacing

Complete

BiV pacing

No AVJ ablation

No CRT

AVJ ablation

and No CRT

AVJ ablation

and no CRT

AVJ ablation

No AVJ ablation

Brignole et al: EHJ 34:2281, 2013


Af in patients with heart failure role of avn ablation and crt

AF and HF

ACC Florida, 2014


Af in patients with heart failure role of avn ablation and crt

Functional class

I

SOLVD, 1992

SOLVD, 1991

II-III

V-HeFT, 1991

CHF-STAT, 1991

III-IV

Stevenson, 1996

GESICA, 1994

IV

CONSENSUS, 1987

Patients (%)

European Survey of Primary Care Physicians

  • 15 countries

  • 1,363 physicians

  • 11,062 pt

  • 1999-2000

Atrial fib

22%

Symptoms

Moderate  severe

41%

Cleland J: Lancet, 2002

Atrial Fibrillation in Heart Failure

Stevenson W

CP1090494-1


Af in patients with heart failure role of avn ablation and crt

Heart Failure, Left Atrial Size and Tissue Fibrosis

A

*

B

*

Avg atrial %fibrosis

LA area (cm2)

Control

CHF

Control

CHF

C

D

Cha, AJP 2003

CP1068448-51


Af in patients with heart failure role of avn ablation and crt

60

60

60

40

40

EF(%)

30

20

0

AF 120

AF 70

AF 76

AF 70

Heart rate (bpm)

Serial Changes in EF

80-Year-Old Female

*Heart rate 140 one week earlier

Grogan M: AJC 69:1573, 1992

CP1000536-4


Af adverse effect of irregular rate

Cardiac Output

Wedge Pressure

8

25

AF–Adverse Effect of Irregular Rate

P<0.002

20

P<0.01

6

15

mmHg

L/min

4

10

2

5

0

0

VVI

VVT

VVI

VVT

VVI = regular rate at mean AF rate

VVT = irregular rate tracking AF

Clark et al: JACC, 1997

CP942080-15


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