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La gestione della fibrillazione atriale nel paziente con insufficienza cardiaca:

La gestione della fibrillazione atriale nel paziente con insufficienza cardiaca: quando conservativi, quando aggressivi. Andrea Mortara. Dipartimento di Cardiologia e Unita’ Scompenso POLICLINICO DI MONZA, Monza. Incontro con gli Esperti, Milano Settembre 2007.

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La gestione della fibrillazione atriale nel paziente con insufficienza cardiaca:

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  1. La gestione della fibrillazione atriale nel paziente con insufficienza cardiaca: quando conservativi, quando aggressivi Andrea Mortara Dipartimento di Cardiologia e Unita’ Scompenso POLICLINICO DI MONZA, Monza Incontro con gli Esperti, Milano Settembre 2007

  2. Age-specific prevalence (per 10 000 population) of hospitalizations for atrial fib among adults age 35 yrs or older by year, 1985 to 1999 Concomitant Heart Failure: 13 % age 35 – 64 yrs 21% age > 65 yrs Wattigney, W. A. et al. Circulation 2003;108:711-716 Atrial fibrillation is increasing FA sta aumentando negli anni FA e’ relata all’eta’ anche nello SC

  3. 20% of patients with heart failure develop AF within 4 years Unadjusted cumulative incidence of first AF after Heart Failure - Framingham Study CHF FA 54 per mille/persone/anno FA CHF 33 per mille/persone/anno Development of AF was associated with increased mortality: hazard ratio of 1.6 (95% CI, 1.2 to 2.1) in men and 2.7 (95% CI, 2.0 to 3.6) in women. Wang, T. J. et al. Circulation 2003;107:2920-2925

  4. Development of AF is associated with Clinical deterioration in Heart Failure(Pozzoli et al JACC 1999) • Prospective follow-up of 344 patients with CHF and sinus rhythm for 19 ± 12 months. • 28 patients developed AF which became permanent in 18 pts • When AF occurred • NYHA class worsened (from 2.4 ± 0.5 to 2.9 ± 0.6, p = 0.0001), • peak exercise O2 consumption declined (from 16 ± 5 to 11 ± 5 ml/kg per min, p = 0.002), • cardiac index decreased (from 2.2 ± 0.4 to 1.8 ± 0.4, p = 0.0008), • mitral and tricuspid regurgitation increased • thromboembolism occurred in 3 of the 18 patients with AF. • 9 of 18 patients died after AF • occurrence of AF was a predictor of major cardiac events.

  5. Pozzoli et al. 1998;31(1):197-204.

  6. Atrial Fibrillation is Associated with increased Mortality in Heart FailureDries et al SOLVD JACC 1998 Atrial Fib Sinus p n 419 6098 Mortality 34% 23% <0.0001 Heart Failure Death 17% 9% <0.0001 Arrhythmic Death 7% 6% NS RR 1.34 (1.11 - 1.61) adjusted for severity, medication

  7. The DIG Investigators. Chest. 2000;118:914-922. From: Shivkumar, Weiss, Fonarow, and Narula; eds. Braunwald’s Atlas of EP in HF.

  8. Atrial Fibrillation and risk of events in the CHARM Trial (JACC 2006)

  9. Pedersen OD Diamond Study Group, Circulation 2001

  10. Atrial Fibrillation and Stroke: Meta-AnalysisHart et al, Ann Intern Med 1999; 131:492 • Risk of stroke 6% per yr (5 - 6 fold increase) • Warfarin (INR 2.0 - 2.6): • 62% reduction (CI 48% - 72%) • N° needed to treat to prevent 1 stroke: 37 • intracranial hemorrhage: 0.3% / yr • major hemorrhage: 0.6% / yr • 20% of patients discontinue anticoagulation • Aspirin (25 mg - 1300 mg/day) • 22% reduction (2% - 38%)

  11. The elderly are particularly vulnerable to stroke when atrial fibrillation is present. Stroke and cardiovascular condition Framingham study (Wolf, 1991)

  12. Atrial fibrillation In Dogs with Rapid Ventricular Pacing-Induced HF(Stambler et al JCE 2003;14:499) • CHF induced by 3 wks of rapid ventricular pacing • Inducible focal atrial tachycardias consistent with triggerred automaticity associated with Ca+2 overload • Atrial fibrosis • Prolongation of atrial action potential duration

  13. Dynamic Nature of Atrial Fibrillation Substrate During Development and Reversal of Heart Failure in Dogs Shinagawa, K. et al. Circulation 2002;105:2672-2678 Baseline Heart failure induced by rapid ventricular pacing Recovery from heart failure (5 weeks) Masson trichrome-stained transverse LA sections from 1 representative dog per group (original magnification x400)

  14. Rapid heart rates depress contractility: abnormal force - frequency in relationship in heart failure 200 Nonfailing Failing 100 % change in Force 0 20 60 120 180 Heart Rate (beats / min) Pieske Circ Res 1999; Gwathmey JCI 1990; Mulieri Circulation 1992; Heerdt PM, Circulation. 2000;102:2713-9.

  15. Adverse Hemodynamic Effects of AF Irregular RR Intervals Impair Cardiac Performance *p < 0.01 N=16 Cardiac Output (L/Min) Cardiac Output (L/Min) NSR AF VVI VVI VVT 60 AVG VVI -AVG VVT Clark DM. JACC 1997; 30:1039-45

  16. Changes of CI in patients who did and did not develop AF (Pozzoli et al, JACC 1998) Cardiac index (l/min/m2)

  17. The effects of rate and irregularity on sympathetic nerve activity in human subjects.(Segerson NM et al Heart Rhythm 2007;4:20-6) • It has been shown that atrial fibrillation is associated with an increase in sympathetic nerve activity (SNA) compared with sinus rhythm • Greater degrees of irregularity cause greater sympathoexcitation and that the effects of irregular pacing on SNA are independent of the hemodynamic changes.

  18. Affermazioni dalla letteratura - Lo SCC e’ un fattore di rischio per sviluppare FA - L’insorgenza di FA in pazienti con SCC e’ associato a deterioramento clinico ed emodinamico e ad una peggiore prognosi - I dati danno percio’ una forte motivazione a prevenire e a trattare la FA nello SCC

  19. “….. You will realize that blood gets into the ventricle not through any pull exerted by the distended heart but through the driving force exerted by the beats of auricles ..” W. Harvey 1628

  20. Ablazione della Fibrillazione Atriale nello Scompenso Cardiaco LEFT ATRIUM Posterior basal view R. pulmonary artery L. pulmonary artery R. superior pulmonary vein L. auricle L. superior pulmonary vein L. atrium R. inferior pulmonary vein L. inferior pulmonary vein Coronary sinus

  21. Left Atrium, Posterior Wall Variable Anatomy(Common)

  22. Left Atrium, Posterior Wall

  23. Asirvatham and Friedman. From: Shivkumar, Weiss, Fonarow, and Narula; eds. Braunwald’s Atlas of EP in HF. 2005.

  24. Relativa importanza del trigger verso substrato Modificata da D Parker circulation 2000

  25. Left Atrium, Posterior Wall Pulmonary Vein Isolation

  26. Ablazione della FA Approccio Circonferenziale

  27. Ablazione della Fibrillazione Atriale - Tecniche - Combined Modality Imaging Fluoroscopy (biplane, for rapid 3-D estimates) High resolution gated CT or MRI 3-D electroanatomic mapping Intracardiac echo In the future: Multi-modality image co-registrationcombining real-time anatomy and function… Current

  28. Esophagus Left PVs Right PVs LA Roof LA Appendage Left Atrium (LA) andPulmonary Vein Anatomy 3-D CT Reconstruction (Extreme PA Cranial View)

  29. Catheter Ablation for Atrial Fibrillation in Heart Failure (Hsu LF et al New England J Med 2004) • 58 consecutive patients with heart failure and LVEF <45% • 58 control patients without CHF undergoing AF ablation matched for age, sex • After 12±7 months, 78% of CHF pts vs 84% of controls remained in sinus rhythm (P=0.34) (69 % and 71% without antiarrhythmic drugs • CHF pts had improvement in: • LV ejection fraction 21±13 % • LV diastolic diameter 6±6 mm • LV systolic diameter 8±7 mm • exercise capacity, symptoms, and and QoL • LV EF improved even if rate control before ablation was judged adequate

  30. Quando il controllo del Ritmo nello Scompenso Cardiaco? • Fattori favorevoli al controllo del Ritmo • Primo o infrequenti episodi di FA persistente • FA asintomatica anche permanente, se mai eseguito un tentativo di ripristino RS • FA sintomatica • Difficolta’ di controllo della frequenza • Controindicazioni a TAO • Fattori favorevoli al controllo della Frequenza • Eta’ biologica avanzata • Controindicazione all’amiodarone • Inefficace/i CVE

  31. Catheter Ablation (low estimate) Medical Treatment (low estimate) Catheter Ablation (mean estimate) Medical Treatment (high estimate) Catheter Ablation (high estimate) Cumulative Costs of Atrial Fibrillation Procedure in Ontario Costs equalized at 3.2-8.4 yrs of follow-up Registro Canadese Y. Khaykin, J Cardiovasc Electrophysiol 2006

  32. Effetti Collaterali della Ablazione della FA (6% delle procedure) • Stenosi della vena polmonare • (Non e’ piu’ importante dopo il cambiamento della tecnica) • Tromboembolismi e Stroke • (0-5%. TAO adeguata a ridotto il problema) • Fistola Atrio-Esofagea • (rara, ma molto grave, dipende da estensione ablazione) • Flutter Atriale • Complicanze legate al cateterismo

  33. Ablazione del Nodo AV e Impianto di PM Biv.+ICD • Vantaggi: • Adeguato controllo del ritmo senza farmaci • Regolarizzata la frequenza cardiaca • Svantaggi: • Richiede impianto del PM (ma e’ + ICD) • FA continua: necessaria TAO • Rischio di Torsioni di Punta dopo ablazione AV • Rischio di deterioramento se stimolato da Vdx (Biv.) GN Kay et al Ablate and Pace J Intervent Card Electrophy 1998 Brignole et al Circulation 1998 Geelen P, et al. VF and sudden death after AVJ ablation. PACE 1997;20:343–8. Jordaens L, et al. Sudden death and long term survival . Eur J Card EP 1993;21:102–9. Gasparini M, et al. Long-term follow-up after AV ablation…PACE 2000;23:1925–9. Ozcan C, et al. Long-term survival …. . NEJM 2001;344: 1043–51.

  34. Conservativi Aggressivi 1° Tentativo di CVE, Shock bifasico (TAO, tiroide a posto, PA controllata, terapia beta-bloccante) 2° Tentativo di CVE, Shock bifasico (dopo avere iniziato amiodarone) Tentativo Di ablazione Controllo Della Frequenza HF+FA

  35. Tentativo Di ablazione Controllo Della Frequenza 1° Tentativo di ablazione Tecnica CARTO Digitale/amiodarone Oltre a B-bloccante Cardioversione Elettrica Valutazione in basale e durante sforzo 2° Tentativo di ablazione Tecnica CARTO Monitorare l’efficacia della terapia nel controllare la frequenza FA HF+FA ??

  36. Conservativi Aggressivi Impianto di ICDPM Biventricolare Digitale/amiodarone Oltre a B-bloccante Valutazione in basale e durante sforzo Riduzione progressiva della frequenza di stimolazione Ablazione Nodo AV HF+FA Insufficiente controllo X

  37. STUDI IN CORSO AF-CHF = Controllo del Ritmo vs Frequenza AVERT-HF = Ablazione nodo AV e BIV Pacing CABANA = Ablazione AF superiore a terapia convenzionale

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