AF in Patients with Heart Failure Role of AVN Ablation and CRT
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Transcript of AF in Patients with Heart Failure Role of AVN Ablation and CRT
AF in Patients with Heart FailureRole of AVN Ablation and CRT
Win K. Shen, MD
Professor of Medicine
Mayo Clinic College of Medicine
Chair, Cardiovascular Diseases
Mayo Clinic Arizona
ACC Florida, 2014
DISCLOSUREDISCLOSUREDISCLOSUREDISCLOSURE
Relevant Financial Relationship(s)None
Off Label UsageNone
Relevant Financial Relationship(s)None
Off Label UsageNone
ObjectivesAtrial Fibrillation and Heart Failure
ObjectivesAtrial Fibrillation and Heart Failure
• Cyclical Relationship: MechanismsAF promotes HFHF promotes AF
• A Case StudyIndications for CRTWhat should be the minimum % of pacing? When to ablate the AVN?
• A review of guidelines and consensus
• Cyclical Relationship: MechanismsAF promotes HFHF promotes AF
• A Case StudyIndications for CRTWhat should be the minimum % of pacing? When to ablate the AVN?
• A review of guidelines and consensus
AFib and CHF – Temporal Relations and MortalityAFib and CHF – Temporal Relations and MortalityFramingham StudyFramingham Study
AFib and CHF – Temporal Relations and MortalityAFib and CHF – Temporal Relations and MortalityFramingham StudyFramingham Study
CP1119361-1
MenMen
Impact of incident CHF Impact of incident CHF on mortality (RR+CI)on mortality (RR+CI)
WomenWomen2.72.7
(1.9-3.7)(1.9-3.7)3.13.1
(2.2-4.2)(2.2-4.2)
MenMen
Impact of incident AFib Impact of incident AFib on mortalityon mortality
WomenWomen1.61.6
(1.2-2.1)(1.2-2.1)2.72.7
(2.0-3.6)(2.0-3.6)
Benjamin: Circ, 2003Benjamin: Circ, 2003
Development of CHF in Pt with AFibDevelopment of CHF in Pt with AFib
YearsYears
Cumulative incidence
of CHF
Cumulative incidence
of CHF
Development of AFib in Pt with CHFDevelopment of AFib in Pt with CHF
YearsYears
Cumulative incidence
of AF
Cumulative incidence
of AF
Atrial Fibrillation and CHF Atrial Fibrillation and CHF Atrial Fibrillation and CHF Atrial Fibrillation and CHF
CHF AFCHF AF• Atrial dilatationAtrial dilatation
• Stretch receptor activationStretch receptor activation
• Neuro-humoral modulationNeuro-humoral modulation
• Signal transduction/bioenergeticsSignal transduction/bioenergetics
• Electropysiologic remodelingElectropysiologic remodeling
• FibrosisFibrosis
AutomaticityAutomaticity RefactorinessRefactorinessConductionConduction
A viciousA viciouscyclecycle
• Loss of atrial contractionLoss of atrial contraction
• Impaired ventricular fillingImpaired ventricular filling
• High heart ratesHigh heart rates
EFEF perfusionperfusionNeurohormonal activationNeurohormonal activationSympathetic stimulationSympathetic stimulation
Use of negative inotropic drugsUse of negative inotropic drugs
TriggeredTriggeredactivityactivity
CHFCHF
AtrialAtrialfibrillationfibrillation
CP1110819-1
AFAF CHFCHF
71 year-old man has mixed CM for 2-3 years. He has permanent AF. Despite medical therapy, he has SOB walking 2-3 blocks and worse at higher altitude. Most recent EF was 28%, LVEDD 59 mm. He has been treated with carvedilol, losartan, lasix, simvastatin, ASA, warfarin. EKG is shown, QRSD 150 msec.
71 year-old man has mixed CM for 2-3 years. He has permanent AF. Despite medical therapy, he has SOB walking 2-3 blocks and worse at higher altitude. Most recent EF was 28%, LVEDD 59 mm. He has been treated with carvedilol, losartan, lasix, simvastatin, ASA, warfarin. EKG is shown, QRSD 150 msec.
Case Study
Case Study Case Study
What would you recommend?
1. CRT is indicated (I)
2. CRT can be useful (IIa)
3. CRT may be reasonable (IIb)
4. CRT is not recommended (III)
What would you recommend?
1. CRT is indicated (I)
2. CRT can be useful (IIa)
3. CRT may be reasonable (IIb)
4. CRT is not recommended (III)
Case Study Case Study
If you did implant a CRT, would you recommend AVN ablation?
1. Yes
2. No
If you did implant a CRT, would you recommend AVN ablation?
1. Yes
2. No
Case Study Case Study
If you did not recommend AVN ablation, what would be the desired % of pacing?
1. > 50%
2. > 70%
3. > 90%
4. ~ 100%
If you did not recommend AVN ablation, what would be the desired % of pacing?
1. > 50%
2. > 70%
3. > 90%
4. ~ 100%
CP1313975-1
Recommendations for CRT in Patients With Systolic Heart FailureAHA/ACC/HRS 2012
2012 DBT Focused Update Recommendations Comments
Class I
1. CRT is indicated for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 msec, and NYHA functional class II, III, or ambulatory IV symptoms on GDMT (14- 19). (Level of Evidence: A)
Modified recommendation (specifying CRT in patients with LBBB of !150 msec; expanded to include those with functional class II symptoms).
Class IIa1. CRT can be useful for patients who have LVEF less
than or equal to 35%, sinus rhythm, LBBB with a QRS duration 120 to 149 msec, and NYHA functional class II, III or ambulatory IV symptoms on GDMT. (14-18, 20) (Level of Evidence: A)
New recommendation
(REVERSE, MADIT-CRT, RAFT)
2. CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS greater than or equal to 150 msec, and NYHA functional class III/ambulatory class IV symptoms on GDMT (14-17). (Level of Evidence: A)
New recommendation
3. CRT can be useful for patients on GDMT who have LVEF less than or equal to 35% and meet CRT indications as above who have atrial fibrillation with adequate rate control allowing for near 100% ventricular pacing (21-24). (Level of Evidence: B)
Modified recommendation (wording changed to indicate benefit based on EF rather than functional class; level of evidence changed from C to B).
(PAVE, APAF, RAFT (15% AF)4. CRT can be useful for patients on GDMT who have
LVEF less than or equal to 35%, and are undergoing device placement with anticipated requirement for significant ventricular pacing (23, 25-27). (Level of Evidence: C)
Modified recommendation (functional class expanded; class changed from IIb to IIa).
Cardiac Resynchronization Therapy Permanent AFib
Cardiac Resynchronization Therapy Permanent AFib
Recommendations Classa Levelb
1) Pt with HF, wide QRS and reduced LVEF1) Pt with HF, wide QRS and reduced LVEF; ; CRT should be considered in chronic HF pt, intrinsic CRT should be considered in chronic HF pt, intrinsic QRS ≥120 ms and LVEF ≤35% who remain in NYHA QRS ≥120 ms and LVEF ≤35% who remain in NYHA functional class III and ambulatory IV despite functional class III and ambulatory IV despite adequate medical treatment, provided that a BiV adequate medical treatment, provided that a BiV pacing as close to 100% as possible can pacing as close to 100% as possible can be achievedbe achieved
IIa B
Brignole et al: EHJ 34:2281, 2013
Case Study Case Study
What would you recommend?
1. CRT is indicated (I)
2. CRT can be useful (IIa)
3. CRT may be reasonable (IIb)
4. CRT is not recommended (III)
What would you recommend?
1. CRT is indicated (I)
2. CRT can be useful (IIa)
3. CRT may be reasonable (IIb)
4. CRT is not recommended (III)
Variable BV Pacing in AFVariable BV Pacing in AFVariable BV Pacing in AFVariable BV Pacing in AF
VSR/VTR Conducted AF Response(BV)
Pseudo Fusion
Six Studies Reporting Outcome DataSix Studies Reporting Outcome Datafor AF Patients Undergoing CRT for HFfor AF Patients Undergoing CRT for HFSix Studies Reporting Outcome DataSix Studies Reporting Outcome Data
for AF Patients Undergoing CRT for HFfor AF Patients Undergoing CRT for HF
Ganesan et al: J Am Coll Cardiol 2012;59:719–26
First author, yrFirst author, yr Study typeStudy type NN Inclusion criteriaInclusion criteria
Comparator Comparator intervention intervention
groupsgroups NN Age (yrs)Age (yrs)Male Male (%)(%) AF characteristicsAF characteristics Follow-upFollow-up % BVP% BVP
Molhoek, 2004Molhoek, 2004 Prospective Prospective single-center single-center cohortcohort
6060 Drug-refractory Drug-refractory NYHA III-IV heart NYHA III-IV heart failure, LVEF failure, LVEF 35%, QRS 35%, QRS duration duration 120 ms120 ms
CRT-SRCRT-SRCRT-AF-AVNA+CRT-AF-AVNA+CRT-AF-AVNA-CRT-AF-AVNA-
303017171313
68±868±863±10*63±10*
80809090
100% long-100% long-standing persistent standing persistent AFAF(>3 mos)(>3 mos)
6 mos6 mos Not Not reportedreported
100%100%82%82%
Gasparini, 2006Gasparini, 2006 Prospective 2-Prospective 2-center cohortcenter cohort
673673 Drug-refractory Drug-refractory NYHA NYHA 11 heart 11 heart failure, LVEF failure, LVEF QRS durationQRS duration120 ms120 ms
CRT-SRCRT-SRCRT-AF-AVNA+CRT-AF-AVNA+CRT-AF-AVNA-CRT-AF-AVNA-
5115111141144848 66*66*
8585 100% permanent 100% permanent AFAF
25.2±18 25.2±18 mosmos
98.5±1.8%98.5±1.8%98.4±2.1%98.4±2.1%88.2±3.1%88.2±3.1%
Ferreira, 2008Ferreira, 2008 Retrospective Retrospective single-center single-center cohortcohort
131131 Drug-refractory Drug-refractory NYHA II-IV heart NYHA II-IV heart failure, LVEF failure, LVEF 35%, QRS 35%, QRS duration duration 120 ms120 ms
CRT-SRCRT-SRCRT-AF-AVNA+CRT-AF-AVNA+CRT-AF-AVNA-CRT-AF-AVNA-
787826262727
66±1066±1067±967±970±870±8
747492929696
Not listed for each Not listed for each subgroupsubgroup
6 mos6 mos 95±13%95±13%98±6%98±6%87±19%87±19%
Gasparini, 2008Gasparini, 2008 Retrospective Retrospective multicenter multicenter registry cohortregistry cohort
1,2851,285 Not pre-specifiedNot pre-specified CRT-SRCRT-SRCRT-AF-AVNA+CRT-AF-AVNA+CRt-AF-AVNA-CRt-AF-AVNA-
1,0421,042118118125125
63±1063±1066±966±967±967±9
757578788484
100% permanent 100% permanent AFAF
Median FU Median FU 34 mos34 mos
Not Not reportedreported
98.7±1.8%98.7±1.8%89.4±2.4%89.4±2.4%
Tolosana, 2008Tolosana, 2008 Retrospective Retrospective multicenter multicenter cohortcohort
470470 Drug-refractory Drug-refractory NYHA III-IV heart NYHA III-IV heart failure, LVEF failure, LVEF 35%, QRS 35%, QRS duration duration 120 ms120 ms
CRT-SRCRT-SRCRT-AF-AVNA+CRT-AF-AVNA+CRT-AF-AVNA-CRT-AF-AVNA-
3443441919
107107
67±967±970±770±7
68±1068±10
76768181
100% permanent 100% permanent AFAF
12 mos12 mos Not Not reportedreported
100%100%92±7%92±7%
Dong, 2010Dong, 2010 Retrospective Retrospective single-center single-center cohortcohort
154154 Heart failure Heart failure symptoms symptoms despitedespite
CRT-AF-AVNA+CRT-AF-AVNA+CRT-AF-AVNA-CRT-AF-AVNA-
4545109109
72±972±968±1168±11
84848787
88% permanent AF88% permanent AF Median FUMedian FU274 days274 days
Median FUMedian FU222 days222 days††
99.0%99.0%(95% CI: (95% CI: 95-100%)95-100%)
96.5%96.5%(95% CI: (95% CI:
85.5-99%)85.5-99%)
*Represents mean age of CRT-AF patients as a group; †24% lost to follow-up
Mean Difference in NYHA Functional Class for Mean Difference in NYHA Functional Class for CRT-AF Patients Undergoing AVNA vs Medical CRT-AF Patients Undergoing AVNA vs Medical
Therapy with Rate-Controlling DrugsTherapy with Rate-Controlling Drugs
Mean Difference in NYHA Functional Class for Mean Difference in NYHA Functional Class for CRT-AF Patients Undergoing AVNA vs Medical CRT-AF Patients Undergoing AVNA vs Medical
Therapy with Rate-Controlling DrugsTherapy with Rate-Controlling Drugs
Ganesan et al: J Am Coll Cardiol 2012;59:719–26
Difference Difference in meansStudy name in means P and 95% CI
Molhoek 2004 -0.100 0.572
Ferreira 2008 -0.500 0.000
Dong 2010 -0.300 0.009
-0.339 0.002-20-20 -10-10 00 1010 2020
Favors AVNA+
Favors AVNA-
Case Study Case Study
If you did not recommend AVN ablation, what would be the desired % of pacing?
1. > 50%
2. > 70%
3. > 90%
4. ~ 100%
If you did not recommend AVN ablation, what would be the desired % of pacing?
1. > 50%
2. > 70%
3. > 90%
4. ~ 100%
Case Study CRT-D Implanted (05/22/12)
Case Study CRT-D Implanted (05/22/12)
Case Study Post Implantation EKG (5/22/12)
QRSD 138 msec
Case Study Post Implantation EKG (5/22/12)
QRSD 138 msec
Case Study Follow Up (10/22/13)
Case Study Follow Up (10/22/13)
98% BV pacingQRSD 138 msec, LVEDD 55 mmEF 42%, symptoms improved from II to 1-II
Indication for AVJ Ablation in Patients With Symptomatic Permanent AFib and Optimal
Pharmacological Therapy
Indication for AVJ Ablation in Patients With Symptomatic Permanent AFib and Optimal
Pharmacological TherapyHeart Failure, NYHA
class III–IV and EF <35%
CRT
QRS ≥120 ms
Reduced EF anduncontrollable HR, any QRS
AVJ ablationand no CRT No AVJ ablation
IncompleteBiV pacing
CompleteBiV pacing
AVJ ablation
QRS <120 ms
Adequaterate control
Inadequaterate control
No AVJ ablationNo CRT
AVJ ablationand No CRT
Brignole et al: EHJ 34:2281, 2013
AF and HFAF and HF
ACC Florida, 2014ACC Florida, 2014ACC Florida, 2014ACC Florida, 2014
European Survey of Primary Care PhysiciansEuropean Survey of Primary Care Physicians
• 15 countries• 1,363 physicians• 11,062 pt• 1999-2000
• 15 countries• 1,363 physicians• 11,062 pt• 1999-2000
SymptomsSymptoms
Moderate severe41%
Moderate severe41%
Cleland J: Lancet, 2002Cleland J: Lancet, 2002Cleland J: Lancet, 2002Cleland J: Lancet, 2002 CP1090494-1
Stevenson WStevenson WStevenson WStevenson W
Atrial Fibrillation in Heart FailureAtrial Fibrillation in Heart FailureAtrial Fibrillation in Heart FailureAtrial Fibrillation in Heart Failure
Patients (%)Patients (%)
SOLVD, 1992SOLVD, 1992SOLVD, 1992SOLVD, 1992
SOLVD, 1991SOLVD, 1991SOLVD, 1991SOLVD, 1991
V-HeFT, 1991V-HeFT, 1991V-HeFT, 1991V-HeFT, 1991
CHF-STAT, 1991CHF-STAT, 1991CHF-STAT, 1991CHF-STAT, 1991
Stevenson, 1996Stevenson, 1996Stevenson, 1996Stevenson, 1996
GESICA, 1994GESICA, 1994GESICA, 1994GESICA, 1994
Functional classFunctional classFunctional classFunctional class
CONSENSUS, 1987CONSENSUS, 1987CONSENSUS, 1987CONSENSUS, 1987
0 20 40 60 80 100
IIII
II-IIIII-IIIII-IIIII-III
III-IVIII-IVIII-IVIII-IV
IVIVIVIV
Atrial fib22%
CP1068448-51CP1068448-51
0
10
20
30
CC DD
AAAA BBBB
ControlControlControlControl CHFCHFCHFCHFLA
are
a (c
mL
A a
rea
(cm
22 ))L
A a
rea
(cm
LA
are
a (c
m22 ))
0.0
2.5
5.0
7.5
10.0
ControlControlControlControl CHFCHFCHFCHF
Avg
atr
ial %
Avg
atr
ial %
fib
rosi
sfi
bro
sis
Avg
atr
ial %
Avg
atr
ial %
fib
rosi
sfi
bro
sis
**** ****
Cha, AJP 2003Cha, AJP 2003
Heart Failure, Left Atrial Size and Tissue FibrosisHeart Failure, Left Atrial Size and Tissue Fibrosis
80-Year-Old Female80-Year-Old Female
Grogan M: AJC 69:1573, 1992Grogan M: AJC 69:1573, 1992
Serial Changes in EFSerial Changes in EF
*Heart rate 140 one week earlier*Heart rate 140 one week earlier
00
2020
4040
6060
AF 120AF 120 AF 70AF 70 AF 76AF 76 AF 70AF 70
6060 6060
EFEF(%)(%)
4040
Heart rate (bpm)Heart rate (bpm)
3030
CP1000536-4
AF–Adverse Effect of Irregular RateAF–Adverse Effect of Irregular RateAF–Adverse Effect of Irregular RateAF–Adverse Effect of Irregular Rate
VVIVVI VVIVVI VVTVVTVVTVVTVVI = regular rate at mean AF rate
VVT = irregular rate tracking AF
Clark et al: JACC, 1997
L/minL/min
00
22
44
66
88
Cardiac OutputCardiac Output
P<0.01P<0.01
mmmmHgHg
00
55
1010
1515
2020
2525
Wedge PressureWedge Pressure
P<0.002P<0.002
CP942080-15