Catheter Ablation for AF: Patients, Procedures,...
Transcript of Catheter Ablation for AF: Patients, Procedures,...
Catheter Ablation for AF: Patients, Procedures, Outcomes
John Sapp
Director Heart Rhythm, QEII Health Sciences CentreProfessor of Medicine, Dalhousie University
How can AF hurt your patients?
• Symptoms
• Stroke/Thromboembolism
• Tachycardia-induced cardiomyopathy
The Devil you know?
Rate ControlBeta-blockersCa++ Channel BlockersDigitalis
Rhythm ControlAF Ablation
Amiodarone, Sotalol, Flecainide, Propafenone,Dofetilide, Dronedarone
How to rate control
• Beta-blockers• Verapamil / Diltiazem
• Digoxin? Not dronedarone• Sometimes pacemaker to permit drug therapy• Rarely AVN ablation
How to Rate Control
• Target resting HR < 100– Sometimes a treadmill test or loop recorder is
informative…
• Pill in the pocket rate control and anticoagulation?
Rhythm Control
• Special cases for rhythm control:– Heart failure?– Young age– Highly symptomatic– Resting bradycardia / Athletes
Rhythm Control• Sotalol
– Avoid in elderly women, use of diuretic, renal dysfunction, hypokalemia, prolonged QT
– I start at 80-120 bid…not higher than 160 bid• Flecainide
– Avoid in patients with ventricular scar– I start at 50 mg bid, sometimes 100 bid, rarely
150bid• Propafenone
– Avoid in patients with ventricular scar– I start at 150 bid-tid, rarely 300 tid
Rhythm Control
• Sotalol: Monitor renal function over time, check QTc interval intermittently, concern if >470, reduce dose if >500
• Flecainide: Watch for side-effects—QRS widening, other
• Propafenone: Watch for side-effects—QRS widening, other
Risks
• 4.7% Complications – 1.5% vascular– 1% Perforation/Tamponade– 1% Stroke/TIA
• Rarer Complications– Pulmonary vein stenosis– Phrenic nerve injury– Atrio-esophageal fistula / Death
Ablation Techniques
• Radiofrequency Ablation– Double trans-septal puncture– Point-by-point ablation lesion delivery
encircling the pulmonary veins and electrically isolating them
CryoAblation
• Liquid-Nitrogen-cooled balloon
• Advanced across interatrial septum, and inflated in pulmonary venous ostia
Catheter Ablation for Persistent AF
• Patients with persistent AF have lower success rates with catheter ablation than paroxysmal patients…
Trials to come…• Comparisons of Cryoablation against RF
ablation
• Comparison of cryoablation against antiarrhythmic drug therapy as an early intervention
• Comparison of AF Ablation versus drug therapy with clinical endpoints
Longer Term Outcomes
• Most recurrences occur within the first year after ablation
• Late recurrences:– 87% 1 year, 81% at 2 years, 63% at 5 years…– 85% at 3 years, 75% at 5 years
• Focus still remains on ablation to control AF, not necessarily a cure…
Freedom from AF after AF ablation in patients with LV dysfunction
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Hsu (N=58)
Chen (N=94)
Gentlesk (N=67)
Khan (N=41)
Lutomsky (N=18)
Efremids (N=13)
Choi (N=15)
De Potter (N=36)
MacDonald (N=22)
Hunter (N=26)
AF Free post-ablation
RAFT-AF
• Hypotheses• Catheter ablation-based AF rhythm control as compared with rate
control in patients with HF of either impaired LV function (LVEF ≤ 45%) or preserved LV function (LVEF > 45%) will reduce all-cause mortality or HF hospitalization
• Key Inclusion Criteria:• High burden AF – paroxysmal, persistent, long-term persistent• NYHA class II or III HF• Increased NT-proBNP/BNP
• Intervention:• Rhythm control arm: Catheter ablation ± AAD• Rate control arm: Rest HR<80; 6MW HR <110
Conclusions
• Rhythm control is still directed at symptoms• First-line therapy is still usually antiarrhythmic
drug therapy• I think new technology is improving the
single-procedure success rate• New trials will help us know best technology
for ablation, and role for ablation in heart failure patients with AF