Quando Quando èè inevitabile pensare allinevitabile pensare all ’’ablazione ablazione della fibrillazione atrialedella fibrillazione atriale

Dr. Alessandro ProclemerDr. Alessandro Proclemer

SOC Cardiologia SOC Cardiologia –– Fondazione IRCAB Fondazione IRCAB Az. OspedalieroAz. Ospedaliero --Universitaria Universitaria –– UdineUdine

Lucca 29 novembre 2013Lucca 29 novembre 2013

Kirchhof F et al. Europace 2013;15:1540–56

Proceedings from the fourth Atrial Fibrillation competence NETwork/EHRA consensus conference

Efficacy and safety of catheter ablation versus antiarrhythmic

drugs for atrial fibrillation:a meta-analysis of randomized

trials

Bonanno et al 2010 J Cardiov Med 11;6:408

Nielsen et al. N Engl J Med 2012;367:1587-95

RF Ablation as Initial Therapy in Paroxysmal AF: MANTRA-PAF Clinical Trial

Nielsen et al. N Engl J Med 2012;367:1587-95

RF Ablation as Initial Therapy in Paroxysmal AF

Nielsen et al. N Engl J Med 2012;367:1587-95

RF Ablation as Initial Therapy in Paroxysmal AF

Long-term Outcomes of Catheter Ablation of AF: A Systematic Review and Meta-analysis

> 3 years

Ganesan et al. J Am Heart Assoc. 2013;2:e004549

Long-term Outcomes of Catheter Ablation of AF: A Systematic Review and Meta-analysis

Ganesan et al. J Am Heart Assoc. 2013;2:e004549

PVI – Udine EP Lab experienceEnrollment Period: January 2004 – December 2012

Follow-Up : 54 ± 30 months

Total Paroxysmal Persistent Permanent

N°patients 315 258 (82%) 51 (16%) 6 (2%)

Age (years) 59 ± 10 60 ± 9 58 ± 11 58 ± 10

Male sex234

(74%) 186 (72%) 43 (83%) 5 (83%)

Left atrium AP diameter (mm) 47 + 7 46 + 8 49 + 5 * 51 + 13

Number of episodes per month

/ 18 + 22 / /

N°AA drugs 2 + 1 2 + 1 2 + 1 3 + 2

Amiodarone 200(63%) 152 (59%) 42 (82%)* 6 (100%)*P<0,05

Clinical characteristicsEnrollment Period: January 2004 – December 2012

Total Paroxysmal Persistent Permenent

CHADS-VASC=0 159 (50%) 133 (52%) 22 (43%) 3 (50%)

CHADS-VASC= 1 97 (40%) 80 (31%) 14 (27%) 3 (50%)

CHADS-VASC ≥2 59 (19%) 45 (17%) 15 (29%) 0

Heart disease (27%) (24%)* (44%)* ( 100%)

*P=0,04

Persistent Paroxysmal Total

population

Dilatative

Tachy-

cardiom.

Ipertensive

Ischemic

Ione AF

Procedural dataTotal Paroxysmal Persistent Permanent

Overall procedural time (min) 158± 30 156± 31 165± 26 150± 20

Fluoroscopy time (min) 49± 16 48± 16 53± 16 49± 11

RF time (min) 31 ± 10 31 ± 10 32 ± 9 26± 12

Multiple Procedures 45 (14%) 36 (14%) 9 (18%) 0

Previous Flutter ablation 44(14%) 37 (14%) 5 (10%) 2 (33%)

Concomitant Flutter ablation 84(27%) 75 (29%) 8 (16%) 1(17%)

AF recurrence

Total and Partial success( burden reduction of at least 80% )

Recidiva post ablazioneP=NS

0 12 24 36 48 60 72 84

100

90

80

70

60

50

40

mesi

% li

bera

da

FA

Number at riskGroup: <3

104 77 58 44 30 18 12 3Group: =>3

147 99 79 57 40 24 7 2

Risk of recurrence according to years from first diagnosis

< 3 years

≥3 years

64%

45%

(P<0,0001)

0 12 24 36 48 60 72 84

100

90

80

70

60

50

40

30

20

mesi

% li

bera

da

reci

diva

di F

A

Number at riskGroup: normale

105 83 63 50 34 22 8 2Group: obeso

49 23 21 12 9 6 2 1Group: sovrappeso

97 70 53 39 27 14 9 2

BMI < 25

BMI ≥ 30

BMI 25-29

Risk of recurrence according to BMI

66%

53%

30%

recidiva post ablazione in funzione delle dimensioni eco dell'atrio sinistroP < 0,0001

0 12 24 36 48 60 72 84

100

80

60

40

20

0

mesi

% li

bera

da

FA

Number at riskGroup: 1

113 84 61 39 18 16 3 0Group: 2

58 46 37 35 27 16 10 5Group: 3

80 46 39 27 25 10 6 0

≤ 40mm≤

40-50mm

≥50mm

Risk of recurrence according to LA diameter

63%

57%

32%

Carto-Merge (CT+EA Map)

Male, 45 yrs, paroxysmal idiop. AF Female, 33 yrs, persistent AF, BMI >30 kg/m 2

Left Atrial Sphericity: A New Method to Assess Atrial Remodeling. Impact on the Outcome of AF Ablation

Bisbal F et al J Cardiovasc Electrophysiol 2013:24 ;752-9

Predicted AF recurrence after ablation

By Left Atrial Sphericity and hypertension (HT)Predicted AF recurrence after ablation

By LA Sphericity and hypertension (HT)

MRI of the left atrium: predicting clinical outcomes after atrial fibrillation ablation

Daccarrett M et al. Expert Rev Cardiovasc Ther. 201 1; 9(1): 105–111.

AF Ablation: outcomes in 2013

Single Procedure Multiple Procedure

Optimal Candidate: 60 – 80% 70 – 90%

Moderate Candidate: 45 – 65% 55 – 75%

Poor Candidate: 35 – 50% 45 – 60%

Success is defined as freedom from symptomatic AF at 12 months of follow-up.

Patient Selection for Ablation

Courtesy of Hugh Calkins, MD.

More Optimal Patient Less Optimal Patient

Variable

Symptoms Highly symptomatic Minimally symptomatic

Class I and III drugs failed ≥≥≥≥1 0

AF type Paroxysmal Long-standing persistant

Age Younger (<70 years) Older ( ≥≥≥≥70 years)

LA size Smaller (<5.0 cm) Larger ( ≥≥≥≥5.0 cm)

Ejection fraction Normal Reduced

Congestive heart failure No Yes

Other cardiac disease No Yes

Pulmonary disease No Yes

Sleep apnea No Yes

Obesity No Yes

Prior stroke/TIA No Yes

Conclusions

• The long-term freedom of atrial arrhythmia can be achieved after AF ablation in the majority of cases, taking into account the need for multiple procedures

• Success rates are dependent on the intensity of

monitoring, the definition of success, the AF

type and several clinical and laboratory

parameters

• A personalized atrial fibrillation management

should be considered even before AF ablation

Catheter Ablation for Atrial Fibrillation

Weerasooriya et al. J Am Coll Cardiol 2011;57:160–6

Weerasooriya et al. J Am Coll Cardiol 2011;57:160–6

Single ablation attempt

Last ablation attempt

Catheter Ablation for AF in 100 pts: 5 yrs FU

NAVISTAR ® THERMOCOOL ® Trial• N = 159 patients• 56 + 11 years• 67% male

0 100 200 300 400 500

Days

0%

20%

40%

60%

80%

100%

Tre

atm

ent S

ucce

ss

Primary Effectiveness Analysis Treatment Success

BlankedforDetectableAF

vs 7.3% (SE 2.9%)vs 7.3% (SE 2.9%)

CRYO 69.9% 114 / 163 CRYO 69.9% 114 / 163

DRUG 7.3% 6 / 82DRUG 7.3% 6 / 82

30 days

KM estimate 68.6% (SE 3.9%)KM estimate 68.6% (SE 3.9%)

OR = 29.5 (12.0 – 72.2) p < 0.001

• Safety and efficacy of the catheter ablation in:

- very elderly

- heart failure

- long standing persistent AF

• Impact of AF ablation on stroke risk.

• Impact of AF ablation on survival.

• Technical questions.

- optimal ablation strategy for long standing persis tent

AF

- relative efficacy of cryo ablation, RF ablation, a nd laser

ablation

Where Are the Knowledge Gaps?

Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial

Narayan et al. J Am Coll Cardiol 2012;60:628-36

Narayan et al. J Am Coll Cardiol 2012;60:628-36

Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial

Narayan et al. J Am Coll Cardiol 2012;60:628-36

Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial

Narayan et al. J Am Coll Cardiol 2012;60:628-36

Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial

Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU

Ouyang et al. Circulation. 2010;122:2368-2377

Ouyang et al. Circulation. 2010;122:2368-2377

Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU

Ouyang et al. Circulation. 2010;122:2368-2377

Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU

Catheter Ablation for Atrial Fibrillation

Weerasooriya et al. J Am Coll Cardiol 2011;57:160–6

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Time to recurrence of AF influences outcome following catheter ablation

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Time to recurrence of AF influences outcome following catheter ablation

Time to recurrence of AF influences outcome following catheter ablation

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Time to recurrence of AF influences outcome following catheter ablation

Piccini et al. Circulation. 2012;126:2200-2207

Outcomes of Medicare Beneficiaries Undergoing Catheter Ablation for AF: 15423 pts, 2007-2009

AFib Recurrence

P HR 95% CI

Age 0,7463 1,00 0,9793 - 1,0297

Sex (F) 0,7105 1,12 0,6195 - 2,0219

BMI ≥ 30 <0.0001 4,6 2,5782 - 8,3563

BMI : 25-29 0,004101 2,3 1,3005 - 3,9601

Years from first

diagnosis0,1593 1,04 0,9857 - 1,0935

CHADS-Vasc 0,6324 0,88 0,5237 - 1,4801

Structural heart

disease0,6381 1,65 0,2067 - 13,1763

LA diameter <0.0001 1,1 1,0574 - 1,1048

Overall procedural time 0,3858 1,00 0,9946 - 1,0142

RF time 0,6717 1,00 0,9814 - 1,0297

Fluoroscopy time 0,7086 0,10 0,9766 - 1,0162

Persistent AFib 0,6567 1,14 0,6359 - 2,0545

Procedure without EA

mapping0,02361 1,6 1,0705 - 2,4990

Univariate/multivariate Cox proportional hazards analyses

Risk of recurrence according to mapping system

Total number 30 (9,5%)

Major complications 20 (6,3%)

Cardiac tamponade 5 (1,6%)

Pericadial effusion 5 (1,6%)

Ictus/TIA 2 (0,6%)

Cerebral hemorrhage 1 (<0,5%)

PV stenosis 1 (<0,5%)

Local hematoma 10 (3,2%)

Retroperitoneal hematoma 1 (<0,5%)

Arteriovenous fistula 4 (1,3%)

Phrenic nerve injury 1 (<0,5%)

Complications

RF Ablation as Initial Therapy in Paroxysmal AF

Nielsen et al. N Engl J Med 2012;367:1587-95

Symptomatic and Asymptomatic Episodes of AF Before and After Catheter Ablation (DISCERN AF)

Verma et al. JAMA Intern Med. 2013;173(2):149-156

Verma et al. JAMA Intern Med. 2013;173(2):149-156

Symptomatic and Asymptomatic Episodes of AF Before and After Catheter Ablation (DISCERN AF)

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Time to recurrence of AF influences outcome following catheter ablation

Gaztanaga et al. Heart Rhythm 2013;10:2–9

Time to recurrence of AF influences outcome following catheter ablation

CRT with mild HF: a systematic review and meta-analysis

Santangeli et al. J Interv Card Electrophysiol 2011;32:125-35

Ganesan et al. J Am Heart Assoc. 2013;2:e004549

Long-term Outcomes of Catheter Ablation of AF: A Systematic Review and Meta-analysis