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Update on the Treatment of Atrial Fibrillation

Update on the Treatment of Atrial Fibrillation. Gregory K. Feld , MD Professor of Medicine Director, Cardiac EP Program. Electrocardiogram of Atrial Fibrillation. Atrial Arrhythmia-Related Hospitalizations in the U.S. Paroxysmal Supraventricular Tachycardia - 6%. Premature beats - 6%.

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Update on the Treatment of Atrial Fibrillation

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  1. Update on the Treatment of Atrial Fibrillation Gregory K. Feld, MD Professor of Medicine Director, Cardiac EP Program

  2. Electrocardiogram of Atrial Fibrillation

  3. Atrial Arrhythmia-Related Hospitalizations in the U.S. Paroxysmal Supraventricular Tachycardia - 6% Premature beats - 6% Atrial Flutter - 4% Atrial Fibrillation - 21% Sick Sinus Syndrome - 9% Conduction Abnormailites - 8% Ventricular Fibrillation - 2% Miscellaneous - 21% Ventricular Tachycardia - 10% Stroke rate is approximately 1-3% without anticoagulation Adapted from Bialy et al.

  4. Mechanisms of Atrial Fibrillation: Multiwavelet Reentry, Rapid Rotors and Focal Triggers

  5. Definitions and Mechanisms of Atrial Fibrillation • Paroxysmal Atrial Fibrillation - recurrent, spontaneously converting AF, <7 days, due to focal premature atrial contractions triggering AF or focal atrial tachycardia • Persistent Atrial Fibrillation - recurrent, sustained AF, > 7 days, requiring electrical or pharmacological cardioversion, may be focally triggered but is due to multiple wavelet reentry • Permanent (Accepted) Fibrillation - permanent AF due to multiple wavelet reentry, abnormal atrial substrate

  6. Why Restore Sinus Rhythm? • Reduce symptoms • Decrease stroke risk • Preserve ventricular function • Reduce mortality

  7. TEE Demonstrating LA Thrombus in Patient with AF

  8. CHADS2 Risk Score • Congestive Heart Failure = 1 • Hypertension = 1 • Age > 75 years = 1 • Diabetes = 1 • Stroke = 2 Anticoagulation with full dose warfarin (INR 2-3) is recommended in any patient with CHADS2 score ≥ 2, with ASA 81-325 mg or warfarin if CHADS2 score is 1, no anticoagulation if CHADS2 score is 0

  9. Antiarrhythmic Drugs for Treatment of Atrial Fibrillation • Class I Drugs • IA (avoid in patients with CAD, LVH, CM) • Disopyramide for vagally mediated AF • IC (avoid in pts with CAD, LVH, CM) • Flecainide 100-225mg bid • Propafenone 150-225 mg tid or bid • Class III Drugs • Sotalol 80-160 mg bid (may not be tolerated in CHF) • Dofetilide 0.125-0.625 mg bid (may be used in CHF, but must watch QTc, K+, creatinine) • Amiodarone 100-200 mg daily (drug of choice in pts with CHF)

  10. Non-Antiarrhythmic Drug Therapy for Atrial Fibrillation • ACE/ARB – reduction in myocardial fibrosis may result in reduced recurrence of AF in patients treated with ACE/ARB • Statins – reduced inflammation (CRP) associated with use of statins may reduce recurrence of AF

  11. AFFIRM Trial

  12. AFFIRM Trial

  13. Inadequate Heart Rate Control in Atrial Fibrillation • Average resting heart rate in excess of 100 bpm • Maximum or peak heart rate in excess of 150 bpm during exercise

  14. Clinical Consequences of Inadequate Heart Rate Control in Atrial Fibrillation • Symptoms including palpitations, fatigue, weakness, shortness of breath, chest pain, lightheadedness or syncope • Adverse hemodynamic effects include hypotension, provocation of ischemia, and aggravation of congestive heart failure • Development of a tachycardia mediated cardiomyopathy

  15. LV Dysfunction Due to RVR in Patients with Atrial Fibrillation

  16. Chronic Pharmacologic Rate Control in Atrial Fibrillation • Calcium Channel Blockers: • Verapamil: 180 - 360 mg daily • Diltiazem: 180 - 360 mg daily • Beta Blockers: • Metoprolol: 25 - 100 mg once or twice daily • Cardevolol: 3.125 – 50 mg twice daily • Digoxin: Oral dose 0.125 - 0.5 mg once daily • Combination of above (Assess rate control with continuous ambulatory monitoring)

  17. AV Node Ablation

  18. AV Node Ablation

  19. AV Node Ablation with Complete AV Block and VVIR Pacemaker

  20. Effect of AV Node Ablation and Pacemaker on LVEF in APT Kay GN, et.al. J Interven Cardiac Electrophysiol 1998;2:121–135

  21. Triggering of AF from PV Focus

  22. Triggering of PAF From RSPV

  23. ICE to Guide Transeptal Puncture to Reduce Risk of Perforation

  24. Lasso Catheter Mapping of PV

  25. Lasso™ Guided PV Isolation Before Ablation During Ablation After Ablation I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1 100 ms A PV A A PV

  26. Lasso™ Guided Segmental PVI

  27. Atrial Fibrillation

  28. Restoration of Sinus Rhythm with Exit Block from Incessant PV Focus

  29. Ablation of Incessant PV Focus

  30. PV Isolation

  31. 3D CT Angiogram Imported into Carto™ Mapping System

  32. CPVA plus LALA Guided by Carto™ 3D Mapping

  33. Lasso™ Recordings from RUPV Before CPVA During Sinus Rhythm

  34. Lasso™ Recordings from RUPV After CPVA During Sinus Rhythm

  35. Persistent Atrial Fibrillation

  36. Conversion of AF to Atypical AFL During LA Linear Ablation

  37. Ablation of Atypical Left Atrial Flutter

  38. Efficacy of PVI and CPVA • Paroxysmal AF: 80-85% cure w/ segmental PVI alone* 80-95% cure w/ CPVA, w/ or w/o LALA* • Persistent AF: 20% cure w/ segmental PVI alone 60-85% cure w/ CPVA, w/ or w/o LALA* (* More than one procedure often required to achieve these results)

  39. Segmental PVI vs. CPVA + LALA in Patients with Symptomatic PAF Sawhney N, et.al. Heart Rhythm 2008;5S:S269

  40. Complications Associated with PV Isolation or LA Linear Ablation • PV Isolation • Symptomatic PV stenosis (<1%) • Embolic stroke (0.5-1%) • Pericardial Effusion / Tamponade (1-3%) • LA Linear Ablation • Embolic stroke (0.5 - 1%) • Pericardial effusion / Tampanode (1-3%) • Symptomatic PV stenosis (<1%) • LA flutter (20-40%, ½ require repeat ablation) • Fatal LA to esophageal fistula (<0.1%)

  41. Effects of Segmental PVI vs. AA Drugs on Recurrence of PAF Wazni OM, JAMA. 2005 Jun 1;293(21):2634-40

  42. Effect of CPVA plus LALA vs. AA Drugs on Recurrence of PAF Pappone C, et,al.J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7.

  43. QOL Following Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003

  44. Adverse Event Rates Following Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003

  45. LV Function after AF Ablation in Patients with of Without CHF Hsu LF, et.al., NEJM 351:2372-83, 2004

  46. Observed and Expected Survival After Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003

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