AF Ablation in Patients with Heart Failure

Christian de Chillou, MD, PhD Department of Cardiology – University Hospital Nancy, France

28ème Journée Internationale du Centre Cardio-Thoracique de Monaco

Monaco, 4 Novembre 2016

Introduction - Background

Pathophysiological interactions between AF and HF

Ling LH , et al. Nature Reviews Cardiology 2016;13:131-47

Prevalence of AF in selected trials of patients with HF

Ling LH , et al. Nature Reviews Cardiology 2016;13:131-47

Wang TJ et al. J Circulation 2003;107:2920-5

Framingham population – 1470 patients – mean follow-up = 5.6 years

AF CHF = 3.3% per year CHF FA = 5.4% per year

Atrial Fibrillation & Heart Failure: Epidemiology

Wang TJ et al. J Circulation 2003;107:2920-5

• Framingham population • 1470 participants / Initial Event : AF (n=683), CHF (n=708), AF & CHF (n=79) • Mean Follow-up = 5.6 Years

Atrial Fibrillation & Heart Failure: Prognosis

Kotecha D et al. Lancet 2014;384:2235-43

Effect of β blockers on survival in patients with HF & AF

Sinus Rhythm Group Atrial Fibrillation Group

Rate control or Rhythm control ?

Rate control vs. Rhythm control CHF trial : a dedicated study in patients with HF

Roy D et al. N Engl J Med 2008;358:2667-77

The efficacy of antiarrhythmic drugs is modest to maintain sinus rhythm in patients with persistent AF

Van Gelder IC et al. Arch Int Med 1996;156:2585-92

236 patients – persistent AF

Carlsson J et al. J Am Coll Cardiol 2002;41:1690-6

The choice of ADDs is very limited in patients with HF: amiodarone !

Nieuwlaat R et al. Eur Heart J 2005;26:2422-34 EURO HEART SURVEY Registry

05

1015202530354045

First Episode Paroxysmal Persistent Permanent

HFno HF

The different types of AF at entry in the registry in relation to the presence of HF

15% 19%

23%

43%

21%

34%

22% 23%

p<0.001

Atrial Fibrillation & Heart Failure: Epidemiology

The AFFIRM Investigators Circulation 2004;109:1509-13

The AFFIRM Investigators N Engl J Med 2002;347:1825-33

Survival rate in patients with AF: negative impact of AADs vs. benefit of sinus rhythm

Chen MS et al. J Am Coll Cardiol 2004;43:1004-9 Hsu LF et al. N Engl J Med 2004;351:2373-83

58 pts with CHF Permanent AF =74% Long-term success w/o drugs =78%

University Hospital Bordeaux Cleveland Clinic, Cleveland, Ohio

AF ablation in patients with HF

94 pts with LV dysfunction Persistent / Permanent AF =61% Long-term success w/o drugs =73%

AF ablation in patients with HF: Technical considerations

W. Einthoven Medicine Nobel price award 1924

Recorded in 1910…

AF triggered by PV firing

Diagram of the sites of 69 foci triggering atrial fibrillation in 45 patients. Haïssaguerre M et al. N Engl J Med 1998;339:659-66

Probability of a PV origin >95%

AF triggered by PV firing

AF triggered by PV firing

RF application time : 30 to 50min

AF triggered by PV firing

728/min !

AF triggered by PV firing

From paroxysmal to permanent AF : atrial remodeling

Paroxysmal AF Persistent AF Permanent AF

+ Intensity of atrial remodeling - Single source (PV) Multiple sources

Camm AJ, et al. Eur Heart J 2010;31:2369-429

Focal Mechanism Diffuse Substrate

By Courtesy of Pr. Michel Haïssaguerre

Speed 1/20

Persistent AF ablation of multiple ‘rotors’

Isochronal step = 20ms

Extensive ablation of areas showing the ‘most’ fragmented EGMs…

Long-standing persistent AF ablation of multiple rotors

Isochronal step = 20ms

… regional ‘organisation’ of AF then sinus rhythm resumes…

Long-standing persistent AF ablation of multiple rotors

Balk EM, et al. J Cardiovasc Electrophysiol 2010;21:1208-16

40,2% vs. 23,5%

Long-term single- and multiple-procedure outcome and predictors of success after catheter ablation for persistent AF

Rostock T et al. Heart Rhythm 2011;8:1391-7

AF ablation in patients with HF Data from the literature

Ablation vs. Amiodarone for treatment of persistent AF in patients with CHF : the AATAC multicenter randomized trial

Di Biase L et al. Circulation 2016;133:1637-44

Catheter Ablation Amiodarone

Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials

Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

2008 2014 2011 2013

Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials

Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

Change in LVEF

Change in Minnesota Living With Heart Failure

Catheter Ablation for AF in HF patients: A meta-analysis of randomized controlled trials

Al Halabi S et al. J Am Coll Cardiol EP 2015;1:200-9

Change in 6-minute walk test distance

Change in peak oxygen consumption (VO2)

Upcoming trials relating to heart failure and atrial fibrillation

Kotecha D, Piccini JP. Eur Heart J 2015;36:3250-7

Management of AF in patients with HF

Kirchhof P et al. Eur Heart J 2016 Aug 27. pii:ehw210

Amiodarone withdrawal for side effects Short-term = 10-15% Long-term = 20-50%

2016 ESC Guidelines

2016 ESC Guidelines

Kirchhof P et al. Eur Heart J 2016 Aug 27. pii:ehw210

Conclusions Patients with both AF and HF present unique diagnostic and

management challenges No randomized trials has demonstrated that pharmacological

rhythm control confers a reduction in mortality compared with rate control in patients with both AF and HF

Studies of highly selected populations of patients with both AF and HF indicate that, in the short term, AF ablation improves symptoms of HF, functional capacity, and LVEF

Randomized, controlled trials to evaluate hard clinical outcomes of AF in patients with both AF and HF are currently in progress

Information to patients

1) Sinus rhythm is much better than AF 2) AF ablation is much better than drugs 3) AF ablation to improve symptoms 4) Complication rate is getting lower (especially TIA/stroke) 5) More than one procedure : very likely !