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Current Mangement of Atrial Fibrillation: An .

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Slide 1 :

John D. Hummel, MD Ohio State University Medical Center Ross Heart Hospital Columbus, Ohio Current Mangement of Atrial Fibrillation: An Evidence-Based Approach

Slide 2 :

Learning Objectives Understand the guidelines for anticoagulation and where there is latitude for physician decisionmaking. Be able to discriminate between patients requiring restoration of sinus rhythm vs. rate control alone. Be able to determine when patients should be evaluated for curative ablation.

Slide 3 :

Atrial Fibrillation Easily recognized. Seems to bother healthcare workers as much as patients. Who’s Problem? Internists cardiologists EP.

Slide 4 :

Go A, et al. JAMA. 2001;285:2370-2375. Projected Number of Adults With AF in the US: 1995 to 2050.

Slide 5 :

Atrial Fibrillation: Costs to the Health Care System 35% of arrhythmia hospitalizations Average hospital stay = 5 days Mean cost of hospitalization = $18,800 Does not include: Costs of outpatient cardioversions Costs of drugs/side effects/monitoring Costs of AF-induced strokes Estimated US cost burden 15.7 billion ALOT!!

Slide 6 :

Paroxysmal (Self-terminating) First Detected Permanent Classification of Atrial Fibrillation ACC/AHA/ESC Guidelines Persistent (Not self-terminating)

Slide 7 :

DIAGNOSTIC WORKUP Minimum Evaluation History and physical – Sx with AF, CV dz Electrocardiogram – WPW, BBB, LVH, MI Echocardiogram – LVH, LAE, EF, Valve Dz Labs – TSH, Renal fxn, LFTs Additional Testing ETT – CAD, Exercise induced SVT / AF Holter / Event Monitor – Confirm AF and Sxs TEE – LA clot EPS – SVT triggered AF AHA / ACC / ECS Guidelines 2006

Slide 8 :

Maintenance of SR Pharmacologic Stroke prevention Nonpharmacologic Class IA Class IC Class III ?-blocker Catheter ablation Surgery (MAZE) Pacing Pharmacologic Warfarin Thrombin inhibitor Aspirin Nonpharmacologic Removal / isolation LA appendage Rate control Pharmacologic Ca2+ blockers ?-blockers Digitalis Amiodarone Nonpharmacologic Ablate and pace Prevent remodeling ACE-I ARB AF: TREATMENT OPTIONS Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

Slide 9 :

Risk Factors for Thromboembolism in AF High-Risk Factors Recommended Therapy Previous CVA / TIA / Embolism High-risk factor or > 2 Mitral Stenosis moderate-risk factors Prosthetic heart valve Coumadin INR 2-3 Moderate-Risk Factors (mechanical valve INR > 2.5) Age > 75 yrs HTN 1 moderate-risk factor CHF ASA or Coumadin DM EF < 35% No risk factors Weaker-Risk Factors ASA 81-325mg daily Female CAD Thyrotoxicosis Age 65 – 74 yrs AHA / ACC / ECS Guidelines 2006

Slide 10 :

AF THERAPY ANTITHROMBOTIC RX

Slide 11 :

The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. AFFIRM Trial: Rate vs Rhythm Control Management Strategy Trial Design 5-year, randomized, parallel-group study comparing rate control vs. AARx attempt at NSR Primary endpoint: overall mortality Patient population 4060 patients with AF and risk factors for stroke Mean Age = 69 yo Hx of hypertension: 70.8% CAD: 38.2% Enlarged LA: 64.7% Depressed EF: 26.0%

Slide 12 :

AFFIRM: All-Cause Mortality Rate N: Rhythm N: 2027 2033 1925 1932 1825 1807 1328 1316 774 780 236 255 0 5 10 15 20 25 30 0 1 2 3 4 5 Mortality, % Rate Rhythm p=0.078 unadjusted Time (years) p=0.068 adjusted The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833.

Slide 13 :

* p=0.79 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. AFFIRM: Adverse Events

Slide 14 :

AF Rate vs. Rhythm Control Trials: Implications AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients Continuous anticoagulation seems warranted in all patients with risk factors for stroke Asymptomatic recurrences

Slide 15 :

Atrial fibrillation Rate control – the problem: Increased rates – more symptomatic, greater hemodynamic impact. Persistent increased rates – tachycardia induced cardiomyopathy Rate control – the goal: PAF – control symptomatic tachycardia Chronic afib – mean 24hr HR < 80-90 bpm

Slide 16 :

Atrial fibrillation Rate control – Drug Therapy: Digoxin – controls resting rate, OK in CHF patients . Beta, Ca+2 blockers – controls resting and exercise rates. Best therapy – combination of beta blocker and digoxin. Even in the best of circumstances pacing support is sometimes required

Slide 17 :

Rate control plus anticoagulation preferred Rhythm control preferred No or lesser AF symptoms Longer AF Hx More SHD Toxicity Risk Elderly Greater risk of proarrhythmia Greater AF symptoms Symptoms despite rate control Younger age No or lesser SHD Rx option of class IC AAD In anticoagulation candidates, continue anticoagulation indefinitely APPROACHES TO AF THERAPY

Slide 18 :

Atrial Fibrillation Duration of AF is the best predictor of recurrent AF after cardioversion Dittrich HC. Am J Cardiol. 1989;63:193-197. < 3 Months 3 - 12 Months > 12 Months 100 80 60 40 20 0 Initial One month post-CV Six months post-CV *P = <0.02 Patients in sinus rhythm (%) Length of time in AF prior to cardioversion *

Slide 19 :

AF TREATMENT GOALS AF is rarely life-threatening and is typically recurrent Treatment goals in symptomatic pts ? frequency of recurrences ? duration of recurrences ? severity of recurrences Minimize risk of tachycardia induced cardiomyopathy Safety is primary concern

Slide 20 :

Class IA Quinidine Procainamide Disopyramide Class IC Propafenone Propafenone SR Flecainide Class III Sotalol Amiodarone Dofetilide Miller and Zipes. In: Braunwald, et al (eds). Heart Disease. 6th ed. 2001. Procainamide, disopyramide, and amiodarone are not FDA-approved for treatment of AF. Rhythm Control for AF: Commonly Used Oral Antiarrhythmic Drugs

Slide 21 :

AF Efficacy: Maintaining NSR > 6 Months

Slide 22 :

ORGAN TOXICITY Examples: Lupus, agranulocytosis, thrombocytopenia, optic neuritis, pulmonary fibrosis, hepatitis, etc. Negligible: Dofetilide, flecanide, propafenone, sotalol Acceptible: Azimilide, disopyramide High: Amiodarone, procainamide, quinidine

Slide 23 :

Drug-Induced Proarrhythmia - Torsades

Slide 24 :

Factors Which Influence Ventricular Proarrhythmia Risk Hypokalemia, hypomagnesemia Long QT at baseline CHF / Decreased EF / Ventricular hypertrophy Bradycardia Female gender Reduced drug metabolism or clearance Amiodarone has lowest risk

Slide 25 :

Atrial fibrillation Heart disease Antiarrhythmic None IC Vagal afib Disopyramide HTN IC (if no sig. LVH) CAD Sotalol CHF/Substantial Amiodarone LVH

Slide 26 :

Alternatives to Drug therapy “Non-Pharmacologic Therapy” Coumadin – LAA closure (Watchman) Rate Control – AVN RFA + PCMK AARx – Adjunctive AFL RFA AARX – Curative Afib RFA

Slide 27 :

WATCHMAN® LAA Filter System

Slide 28 :

Complete AVN ablation

Slide 29 :

Pacemaker Placement

Slide 30 :

AVN RF ablation

Slide 31 :

Objective Benefits of AV nodal Ablation Rodriguez LM. Am J Cardiol. 1993;72:1137-1141. A Left ventricular ejection fraction (%) B Left ventricular end systolic diameter (mm) 70 60 50 40 30 20 Before After LVEF (%) mean 54 + 7 p < 0.001 mean 43 + 8 55 50 45 35 30 20 Before After LVESD (mm) mean 34 + 5 p < 0.003 mean 40 + 5 40 25

Slide 32 :

Complete AVN Ablation Advantages: 100% efficacy 85% symptomatic improvement Improved EF (LV remodeling) Eliminates need for rate control drugs Disadvantages: Pacemaker dependant Good Candidates: Tachy / Brady Syndrome PCMK in Place – CHF with BiV device Medication refractory / intolerant Elderly

Slide 33 :

60 F with PAF treated with Rythmol Presented with recurrent tachycardia

Slide 34 :

Atrial Flutter Circuit

Slide 35 :

Atrial Flutter Circuit

Slide 36 :

Atrial Flutter Ablation

Slide 37 :

Atrial Flutter RFA

Slide 38 :

Atrial Flutter Ablation Approximately 15% of AF patients treated with an AA will develop AFL Advantages: 95% efficacy ˜ 80% arrhythmia control if AARx continued As primary Tx RFA more effective than AARx Disadvantages: Invasive Good Candidates: Typical AFL (IVC / TV isthmus) Primary AFL or AARx related AFL

Slide 39 :

Focal Origin of Atrial Fibrillation Hassaiguerre M, NEJM, 1998 94% of AF triggers from Pulmonary Veins “90 – 95% of all AF is initiated by PV ectopy” RA LA CS FO SVC IVC Pulmonary Veins 17 31 6 11

Slide 40 :

74 yo medically refractory AF, Echo – Normal AA Rx - Verapamil, Rythmol, Betapace, Norpace

Slide 41 :

Lasso Catheter

Slide 42 :

Circular Mapping & Ablation Catheter in Right Superior Pulmonary Vein

Slide 43 :

Atrial Fibrillation Ablation Atrial Shell and Cardiac MRI

Slide 44 :

45 yo F with medically refractory Highly Symptomatic PAF

Slide 45 :

45 yo F with Medically Refractory PAF CT Scan / Carto Images – PA View

Slide 46 :

45 yo with PAF Conversion of AF to NSR, LSPV with AF Lasso LSPV CS Abl

Slide 47 :

Current State of Curative Catheter-Based RFA Procedural Success & Complications Total Patients > 800 (70% PAF) Expected success @ 1yr ˜ 70% after first procedure ˜ 80% after second procedure Complications ˜ 2 to 3% Tamponade – 0.6% Pulmonary vein stenosis – 0.6% TIA / CVA – 0.5% Esophageal-LA fistula - 0 Groin Bleeding / Hematoma (Last 200 pts complications < 1%)

Slide 48 :

Atrial Fibrillation: Ablation vs Drug Rx. Ablation 80% success PV stenosis AE fistula TIA/CVA Drug Rx. 50% success Proarrhythmia End Organ Toxicity No Free Lunch PV stenosis AE fistula Torsades

Slide 49 :

Current State of Curative Catheter-Based RFA Who is a good candidate? Symptomatic / Frequent AF Limited Heart Dz EF > 35% LA < 5.5cm No MS / Rheumatic Dz Younger Patients No LA thrombus or Hx of CVA Medically Refractory / Intolerant (Ablation now second line therapy)

Slide 50 :

Industry Estimates: AF Demographics Approximately 26,000 AF ablation procedures (surgery + EP) were performed in 2004. Currently, only about 1% of AF population being addressed with curative therapies. Estimates for EP Afib RFA: 2005 = 19,000 2006 = 21,000 Physicians estimate apporx. 30% of Afib pts are RFA candidates. (1%)

Slide 51 :

The Trouble With a Moving Target Atrial Fibrillation Ablation Evolution of the Moving Target Early Rumors (20 hr cases) 2006 Mid 90’s Right Sided Linear Phrenic Nerve Injury Left Sided Focal Tamponade TIA/CVA PV Isolation PV Stenosis WACA + Linear Esophageal Fistulas Left Atrial Flutters Fractionated Egms Back to the Right Side Hybrid Approaches Need for Stereotaxis, Cryoablation, HIFU? IVUS / Transeptal Lasso 3D Mapping CT integration

Slide 52 :

Atrial Fibrillation New Technology Coming Your Patients Way at Ohio State University Stereotaxis – Magnetic Catheter Navigation Energy Sources High Intensity Focused Ultrasound (HIFU) Cryoablation Balloon Watchman – Left Atrial Appendage Closure

Slide 53 :

A-Fib vs. EP Labs

	SlidesOnline 1 Years ago. Category: Cardiology

Tags:	Cardiology

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