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Brett D. Atwater, M.DAssistant Professor of MedicineDuke University Medical Center
Durham VA Medical Center
NOT Everyone Benefits from Atrial Fibrillation Ablation!
Dr. Kevin Jackson
• Universally loved by patients
• Respected by all of his colleagues
• Right about most things…
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Page 42011 ACCF/AHA/HRS Focused Update on the Management of Patients With
Atrial Fibrillation
My Job is Easy, Just Find a Single Situation Where AF Ablation DOES NOT Benefit a Patient!
Rate vs. Pharmacologic Rhythm Control Trials (6615 Mostly Older Patients with No/Minimal AF Symptoms)
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N Primary Endpoint
HR (Rate vs. Rhythm Control)
P
PIAF 252 Improvement in AF Symptoms
1.10 0.31
AFFIRM 4060 Mortality 0.87 0.08
RACE 522 Composite 0.73 0.11
STAF 200 Composite 1.09 0.99
HOT CAF 205 Composite 1.98 >0.71
AF-CHF 1376 Cardiovascular Mortality
0.94 0.59
Symptoms According to Type of AF
Page 8Michiel Rienstra et al. Circulation. 2012;125:2933-2943
10-20% of patients
Frequency of Rate vs. Rhythm Control Strategies in the Real World, ORBIT-AF
• 68% of patients in US clinics are managed with rate control strategy, 32% with a rhythm control strategy
• Patients followed by EP and more symptomatic patients are more likely to be treated with a rhythm control approach
• If 90% of AF patients have symptoms but only 32% are receiving a rhythm control strategy, likely underusing this strategy
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Am Heart J. 2013 Apr;165(4):622-9
Summary of AF Ablation in Patients with No/Minimal Symptoms (10-20% of AF patients)
• Data support non-inferiority of rate control compared to pharmacological rhythm control approach in older patients with minimally symptomatic AF
• No data supporting use of AF ablation vs. rate control in minimally symptomatic AF
• Guidelines favor use of rate control approach in patients with No/ minimally symptomatic AF
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Pharmacologic Rhythm Control in Symptomatic Patients Trial N F/U
(mos)SR Quality of Life
RACE1 512 27 +29% Improved among patients with AF at enrollment
HOT-CAFÉ2
205 20 NR Improved LVEF and exercise capacity
SAFE-T3 404 12 +10% Improved SF-36
CAFÉ-II4 61 12 +66% Improved SF-36, LVF, NT-BNP
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1. N Engl J Med. 347(23):1834-402. Chest 2004 Aug;126:476-863. N Engl J Med; 352:1861-724. Heart;95:924–930
Ablation for Rhythm Control
n F/U QOL
Milan1 211 12 ImprovedSTOP-AF2 245 12 ImprovedMayo3 502 24 ImprovedBordeaux4 63 12 ImprovedCleveland/ Austin5
1420 15 Improved
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1. J Am Coll Cardiol 2003;42:185–972. Presented at 30th Sessions of HRS, 20103. J Am Coll Cardiol, 2010; 55:2308-23164. Heart Rhythm. 2005 Jun;2(6):619-235. J Am Coll Cardiol, 2012; 59:606
Milan 2003- Ablation vs. AAD
•Mortality Medical•Mortality Ablation•P-
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Mortality Stroke/HF02468
101214161820
AblationMedical Therapy
P< .001 P< .001
Symptomatic AF Management by the Guidelines
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Catheter Ablation is only recommended as first line for symptomatic patients
with paroxysmal AF
Special Circumstances
• No data for use of catheter ablation for management of symptomatic AF in any of the following:– Acute coronary syndrome– Acute HF episode– Acute hyperthyroidism– Postoperative cardiac or thoracic surgery– AF complicating acute pulmonary conditions, including
COPD flare, pneumonia, or PE
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Summary
• AF ablation has not been prospectively tested against a rate control strategy in older patients and those with No/ minimal symptoms
• Rhythm control strategies including AF ablation are probably underused in symptomatic AF patients but not all symptomatic AF patients are good ablation candidates
• AF ablation is recommended as first or second line treatment of young symptomatic patients with paroxysmal AF
• AF ablation is currently second line treatment in older symptomatic patients and in patients with persistent AF
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CABANA Trial- Answers are Coming!
• 2200 patients (2062 enrolled)• Designed to test the hypothesis that ablation of AF
will be superior to current state of the art rate control or pharmacological rhythm control for decreasing the combined incidence of – death– disabling stroke– serious bleeding– cardiac arrest
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