Atrial Fibrillation: Update 2007

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Atrial Fibrillation: Update 2007

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1. Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRS Director, Cardiac Electrophysiology Pinnacle Health System and Associated Cardiologists, PC Harrisburg, PA Clinical Associate Professor of Medicine Pennsylvania State College of Medicine October 13, 2007

2. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis. 2% VF

3. 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.

4. 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

5. 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)

6. AF: Pathophysiology Wavelets

7. AF: Pathophysiology

8. AF: Pathophysiology

9. Why Treat AF?

10. 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

11. Rate Control vs. Rhythm Control Studies AFFIRM (2002) RACE (2002) PAF (2000) STAF (2003) HOT CAFE’ (2004) No study demonstrated a difference in quality of life!

12. 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!

13. Clinical Management

14. Clinical Management

15. Clinical Management

16. Clinical Management: Which AA Drug?

17. Catheter and Surgical Ablation of AF

18. Atrial Fibrillation Ablation: HRS/EHRA/ECAS Expert Consensus Statement Electrophysiologic basis and rationale Patient Selection Methods Complications Appropriate follow-up and long-term management

19. Ablation: Electrophysiologic Basis Traditional Theory: Wavelets

21. Embryology of the Pulmonary Veins

22. Pulmonary Veins

23. Catheter Ablation of AF: Different Approaches

24. 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.

25. Complications Cardiac tamponade Pulmonary vein stenosis Atrio-esophageal fistula Phrenic nerve injury Thromboembolism

26. Complications Air embolism Post-procedural arrhythmias Vascular complications Acute coronary occlusion Periesophageal vagal injury

27. 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.

28. 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.

29. 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%.

30. 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.

31. 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.

32. 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%

33. 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

34. Catheter Ablation of AF J Cardiovasc Electrophysiol. 2006;17:1-6

37. Surgical Ablation of AF Concomitant to other open heart operations. Stand alone surgery for AF.

38. 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.

39. 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.

40. Stand-alone Surgical Ablation

41. Cox MAZE III Procedure

45. Bipolar clamp ablation

46. Gross Pathology Above, a lesion created with the AtriCure system is shown on the epicardial surface of an atrial appendage. Lesions created with the AtriCure system are typically very narrow and discreet in nature. When the atrial appendage is invaginated, the endocardial lesion is seen. The electrodes of the AtriCure Handpiece never came in contact with this endocardial surface.Above, a lesion created with the AtriCure system is shown on the epicardial surface of an atrial appendage. Lesions created with the AtriCure system are typically very narrow and discreet in nature. When the atrial appendage is invaginated, the endocardial lesion is seen. The electrodes of the AtriCure Handpiece never came in contact with this endocardial surface.

47. Stand-alone Surgical Ablation of AF

48. Thromboembolic Risk: Pathophysiology Wyse and Gersch, Circulation, 2004;109:3089-3095

49. Thromboembolic Risk Stratification: Who Needs Anticoagulation?

50. Thromboembolic Risk Stratification: Who Needs Anticoagulation?

51. Thromboembolic Risk Stratification: Who Needs Anticoagulation?

52. Thromboembolic Risk Stratification: Who Needs Anticoagulation?

53. 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.

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