1. Recent Developments in the Management of Atrial Fibrillation Greg C. Flaker, MD Brent Parker Professor of Medicine University of Missouri - Columbia

2. Recent Developments in AF Rate control AV junction ablation/ modification Rhythm control Focal ablation Surgery (MAZE) Catheter based Combined Devices Stroke Prevention

8. AFFIRM TrialHazard Ratios for Survival ● ● ● Favorable Unfavorable CHF LV Dysfunction NSR Warfarin Digoxin Rhythm Control Drug ● ● ● 0.5 1.0 1.5 Circ 2004;109:1909

9. Radiofrequency Catheter Ablation: What’s Hot?.

11. Long-term Survival after Pace/ablate NEJM 2001; 344: 1043-51

12. AV Node Ablation forAtrial Fibrillation Pro’s Con’s Simple Pacemaker dependence High success Permanent Improved QOL Anticoagulation regular rate controlled rate “When the rate cannot be controlled with pharmacologic agents or tachycardia-mediated cardiomyopathy is suspected, catheter directed ablation of the AV node may be considered.” Class IIb, Level of evidence C “It is reasonable to use ablation of the AV node or accessory pathway to control heart rate when pharmacologic therapy is insufficient or associated with side effects.” Class IIa, Level of evidence C Circulation 2006;114:700-752

13. Acute MI Pacemaker LVEF 5-01 10-01 2-03 6-03 9-03 DATE

14. Wide QRS – Proportional Mortality Increase QRS Duration (msec) • Vesnarinone Study1(VEST study analysis) • NYHA Class II-IV patients • 3,654 ECGs digitally scanned • Age, creatinine, LVEF, heart rate, and QRS duration found to be independent predictors of mortality • Relative risk of widest QRS group 5x greater than narrowest <90 90-120 120-170 170-220 >220 Adapted from Gottipaty et al. 1Gottipaty V, Krelis S, et al. ACC 1999 [Abstr];847-4.

15. Ventricular Desynchronization due to RV Apical Pacing (LBBB) Sinus node AV node • ?Decreased LVEF/LVFS • ?Increased LVEDD • ?Increased ESV • ?LV remodeling • ?Increased LA diameter Conduction block Pacemaker

16. RV apical pacing paced QRS duration 194ms

17. Pacemaker analysis

18. MORE PACING = MORE HEART FAILURE Sweeney et al. Circulation 2003;107:2932)

19. pQRS Duration Predicts Heart Failure % with CHF hospitalization Shukla PACE 2004

21. JS QRS duration 139msec.

22. PAVE Study • chronic AF patients • NYHA I, II,III • AV junction ablation J Cardiovascular Electrophysiology 2005; 16(11): 1160-5

23. PAVE Study

24. PAVE Study

25. Recent developments in AF Rate control AV junction ablation/ modification Rhythm control Focal ablation Surgery (MAZE) Catheter based Combined Devices Stroke Prevention

26. N=7401 N=7401 N=4060 N=4060

27. Devices for AF: Living Better Electrically N Engl J Med 2002;346(26):2066

28. AF is reduced with dual chamber pacing N Engl J Med 2002;346(24):1857

37. EP Peripheral Based Therapy Catheter Approach

38. Endocardial ablation for atrial fibrillation: 2007 Focal ablation Linear ablation paroxysmal AF chronic AF no structural disease remodeled atria success rate 60-80% success rates ?

39. Catheter Based Pulmonary Vein Isolation – The Goal L superior PV R superior PV L inferior PV R inferior PV Complete Isolation of Each Pulmonary Vein Orifice

40. Catheter Ablation Challenges Long Term Results Freedom from AF Oral H., Pulmonary Vein Isolation for Paroxysmal… Circulation 2002;105(9):1077-81.

41. AtriCure Instrument Tip Bias Insures Uniform Tissue Contact Sliding Jaw Fixed Jaw Self Adjusting Internal Spring Provides Uniform Pressure on Tissue

42. MIS Approach – Wolf Mini-MazeThe Next Step in Evolution in Surgical Ablation • Sole paroxysmal and persistent AF patients • Bi-lateral pulmonary vein isolation – 90+% success • Close left atrial appendage to manage stroke • Collaborate with EP partners with dual approach

43. Pulmonary Vein IsolationGanglionic Plexis AblationLeft Atrial Appendage Exclusion Procedure Steps This material is intended to provide general information, including opinions and recommendations, contained herein for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. The material is not intended to direct clinical care in any specific circumstance. The judgment regarding a particular clinical procedure or treatment plan must be made by a qualified physician in light of the clinical data presented by the patient and the diagnostic and treatment options available. This material may contain uses of AtriCure devices for the surgical treatment of atrial fibrillation which are investigational and have not been approved by the U.S. Food and Drug Administration. Please review the Instructions for Use for a complete listing of indications, contraindications, warning, precautions, potential adverse events and Directions for Use prior to using these devices. Federal Law (USA) restricts these devices to sale, distribution, or use by or on the order of a physician.

44. SVC R1 RSPV R3 R2 RA LA R4 R5 Waterston’s Groove RIPV R6 R7 R8 R9 R10 IVC Ganglionic Plexi - Right

45. Pulmonary Artery L2 L1 LSPV LA Appendage L4 L3 Marshall Tract L6 L5 LIPV L8 LA L7 LV L10 L9 AV Groove Ganglionic Plexi - Left

46. Silent Atrial Fibrillation:Special Populations Catheter ablation 19% Pacemaker population 18% Circulation 2002;106:II-52 Circulation 2003;107:1614

47. Rhythm Control : Antiarrhythmic Drugs vs Catheter Ablation Circulation 2006;114:700-52

48. Recent developments in AF Rate control AV junction ablation/ modification Rhythm control Focal ablation Surgery (MAZE) Catheter based Combined Devices Stroke Prevention

49. Congestive heart failure Hypertension Age > 75 years Diabetes mellitus Stroke or TIA PointsRisk of stroke/100pt-years 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2 Stroke Prevention in Atrial Fibrillation: CHADS2 JAMA 2001;285:2864

50. Oral Anticoagulant and Aspirin Use in Atrial Fibrillation from 1980 to 2000 Minidose Warfarin Study AFASAK II LASAF EAFT Oral Anticoagulant PATAF SPAF II Aspirin SPINAF SPAF III Japanese NVAF study SPAF I CAFA BAATAF AFASAK I