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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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Af burden l.jpg
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


Are effective treatments available l.jpg
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


Non pharmacological methods l.jpg
Non pharmacological methods

  • Pacemaker

    • Pace to suppress triggers of AF

    • Multisite or biatrial pacing

  • Atrial defibrillators

  • Surgical ablation

  • Catheter ablation



Ablation strategies l.jpg

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






Worldwide survey of af ablation cappato et al esc 2004 l.jpg
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


St bartholomew s data l.jpg
St Bartholomew’s data

  • PATS database (EP and EP2)

  • Research database

    • Catheter maze study

    • Coarse AF study

  • Patient letters

    • DMS/EPR viewer

  • Telephone patients


Total number of procedures l.jpg
Total number of procedures

100 procedures in 73 patients



Patients l.jpg
Patients

N=73 50±8 years 58M 15F

Type of AF:

Cardiac diagnosis:





Need for repeat procedures l.jpg
Need for repeat procedures?

Number of procedures per patient:


Success of 1 st procedure l.jpg
Success of 1st procedure


Procedure times l.jpg
Procedure times

281±120

49±25


Complications l.jpg

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


Catheter maze study l.jpg
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


Catheter maze outcome l.jpg
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


Results symptoms and qol l.jpg
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


Surgical maze bracus stidy l.jpg
Surgical Maze – BRACUS stidy

  • Bipolar Radiofrequency Ablation for Chronic atrial fibrillation in patients Undergoing mitral valve Surgery


Conclusions l.jpg
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


St bartholomew s as a lead national centre for af ablation l.jpg
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