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Clinical Title
Date
Jaret Tyler, MDClinical Cardiac ElectrophysiologistAssistant Professor of MedicineOhio State’s Heart and Vascular Center
Atrial Fibrillation:How Your “Type” Affects Your Treatment
July 10th, 2013
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Disclosures
2
None
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Objectives
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What Is Atrial Fibrillation? Epidemiology Risk Factors Classification or “Type”
Mechanisms Trigger and Substrate
Treatment Medications, Ablations, Devices
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Atrial Fibrillation
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Definition Common supraventricular arrhythmia
characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function
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Atrial Fibrillation
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Most common arrhythmia in clinical practice
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Atrial Fibrillation
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Atrial Fibrillation
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Modifiable Obesity Sleep Apnea Alcohol – “Holiday Heart” HTN
Medical conditions Diabetes Thyroid Disease Structural Heart Disease COPD / PTE
Non-Modifiable Genetic disorders Age Sex – Male Tall stature
Pericarditis/Myocarditis Surgery Other Arrhythmias MI
Risk Factors for AF
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“Types”
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Paroxysmal AF Recurrent AF (≥ 2 episodes) that terminates
spontaneously within 7 days Episodes ≤ 48 hours duration that are terminated
with electrical or pharmacologic cardioversion
Persistent AF Continuous AF that is sustained beyond 7 days
Episodes ≥ 48 hours but < 7 days that are terminated with electrical or pharmacologic cardioversion
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“Types”
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Longstanding Persistent AF Continuous AF of > 12 months duration
Permanent AF Decision made not to restore or maintain sinus
rhythm by any means Therapeutic attitude not pathophysiological
attribute
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Mechanisms of Atrial Fibrillation
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Mechanisms of Atrial Fibrillation
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Mechanisms of Atrial Fibrillation
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Mechanisms of Atrial Fibrillation
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Mechanisms of Atrial fibrillation
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Mechanisms of Atrial Fibrillation
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Treatment of Atrial Fibrillation
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Acute Anticoagulate and Rate Control
“Type” does not affect choice of anticoagulant or method of rate control
First Occurrence?
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Treatment of Atrial Fibrillation
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Goals of Long-Term Treatment
Anticoagulation to prevent stroke
Prevention of tachycardia-induced cardiomyopathy
Improvement in symptoms, functional capacity, and quality of life
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Treatment of Atrial Fibrillation
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Stroke Risk and Reduction
AF is an independent risk factor for stroke
CHADS2 or CHA2DS2-VASc
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C – Congestive Heart Failure
H – Hypertension
A – Age > 75 years
D – Diabetes Mellitus
S2 – Stroke or TIA history
C – Congestive Heart Failure
H – Hypertension
A2 – Age > 75 years
D – Diabetes Mellitus
S2 – Stroke or TIA history
V – Vascular Dz or CAD
A – Age > 65 years
Sc – Sex
Treatment of Atrial Fibrillation
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Treatment of Atrial Fibrillation
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Treatment of Atrial Fibrillation
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No Risk Factor ASA 81 – 325 mg daily
1 Point ASA 81 – 325 mg daily, or oral coagulant
≥ 2 Points Oral anticoagulant
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Treatment of Atrial Flutter
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No Risk Factor ASA 81 – 325 mg daily
1 Point ASA 81 – 325 mg daily, or oral coagulant
≥ 2 Points Oral anticoagulant
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Treatment of Atrial Fibrillation
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Asymptomatic Rate control
Symptomatic Rate control Rhythm control
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Anti-Arrhythmic Drugs
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Why Ablate AF?
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Decrease stroke risk Decrease heart failure risk Improve survival Get off anticoagulation Improvement in quality of life
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Treatment of Atrial Fibrillation
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Catheter Ablation Recommended for patients with symptomatic
paroxysmal AF (PAF) who are refractory or intolerant to at least one anti-arrhythmic medication
Most success with PAF but can be used to treat AF of any duration Success rate ~ 40-80%
Recurrence of AF after index AF ablation procedures leads to repeat ablation in up to 50% of patients
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Treatment of Atrial Fibrillation
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Lower Success/ Higher Complications Duration of time a patient has been in continuous
atrial fibrillation (e.g., remodeling/fibrosis) Concomitant heart disease Obesity/Sleep apnea Left atrial size
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Physicians Point of View
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Ablation Approaches
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Targeting Pulmonary Veins
Standard therapy for PAF
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Ablation Approaches
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Ablation Approaches
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Ablation Approaches
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Why not perform linear lesions on everyone? Linear lesions are not easy Gaps Propensity for left atrial flutters
Role of linear lines in persistent AF controversial Persistent and Long-Standing Persistent AF
Stepwise approach PVI CFAE Linear lines
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Ablation Approaches
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PVI is the cornerstone
Focal trigger targeting
Linear Lesions
CTI if flutter
Longstanding persistent Linear lesions and CAFEs
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Management not Affected by “Type”
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Anticoagulation pre and immediately post ablation (2 months)
Pre-operative evaluation with TEE and atrial imaging (CT or MRI)
Event monitor in follow-up
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Early Recurrence of AF Post Ablation
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Anti-Arrhythmic Drugs Post Ablation Irritable, maturing lesions
immediately post ablation
Decrease early recurrenceof atrial arrhythmias
No effect on prediction or prevention of arrhythmia recurrence at 6 months
No effect on PAF vs. Non-PAFablation success
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Efficacy of catheter ablation
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Paroxysmal AF Ablation: 66 – 89%
Long-standing Persistent Ablation: 47%
Medications: 9 – 58%
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Surgical Ablation of Atrial Fibrillation
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Cox/Maze Procedure Dr. James Cox Interrupt all macro-reentrant circuits
Multiple wavelet hypothesis Cox/Maze III
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Surgical Ablation of Atrial Fibrillation
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Cox/Maze III 73 – 80% success
Off anti-arrhythmic medications
Higher incidence of complications 10.7 – 13.9% 8 – 23% needed a pacemaker
Complex, Difficult, Risks
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Surgical Ablation of Atrial Fibrillation
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Replace “Cut-and-Sew” with linear ablation
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Surgical Ablation of Atrial Fibrillation
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Cox/Maze IV 78% sinus Rhythm off anti-arrhythmic meds No difference from Cox/Maze III in freedom from AF Complications 11% Pacemakers 9% post-operatively No difference in paroxysmal vs. persistent or
longstanding persistent (p=0.378) Predictors of recurrence were absence of a box
lesion set, increasing left atrial diameter, and early post-operative arrhythmias
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Surgical Ablation of Atrial Fibrillation
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Summary Need more multicenter clinical trials with uniform
definitions and follow-up Good long-term results Consider for ALL patients with symptomatic AF
undergoing other cardiac surgery Stand-alone surgical ablation is not
recommended prior to initiation of anti-arrhythmic drug therapy
PVI with connection to MV annulus Bi-Atrial procedure for those with persistent and
longstanding persistent AF Complete occlusion of LAA
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Device Therapy for Atrial Fibrillation
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Device Therapy for Atrial Fibrillation
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Pacemakers/ICD do not “cure” atrial fibrillation
Patients with atrial fibrillation have sick sinus syndrome by association
Helpful in Tachy-Brady Syndrome All “Types” of AF, including Permanent AF
AV nodal ablation
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Device Therapy for Atrial Fibrillation
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AV Nodal Ablation Ablate and Pace
Rapid heart rates despite max Rx Often yields remarkable symptom relief
Growing concern for chronic RV pacing
BiV Pacing
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Conclusions
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Atrial Fibrillation is prevalent and affecting more people every year
Continuous evolution of understanding causes
Continuous evolution in treatment strategies, becoming more tailored to one’s AF “Type”
Toddler stages
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Unanswered Questions
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What if I failed catheter ablation? No head-to-head comparisons
What are the comparative success rates of various ablative techniques in differing patient populations, particularly persistent and longstanding persistent AF?
Is there an acceptable rationale for ablation applied as first line therapy for AF?
What are the very long-term outcomes (> 5 years) of catheter and surgical AF ablation?
What “new” technology is on the horizon and how will this affect outcomes?
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Evolution of AF Treatment
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