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Pierre Jaïs, MD, Bordeaux, FrancePierre Jaïs, MD, Bordeaux, France
LIRYC, MUSICLIRYC, MUSIC
IHU LIRYC IHU LIRYC ANR-10-IAHU-04ANR-10-IAHU-04
Equipex MUSIC ANR-11-EQPX-0030Equipex MUSIC ANR-11-EQPX-0030
FP 7 grant: FP 7 grant: HEALTH-F2-2010-261057Stock Holder Cardio InsightStock Holder Cardio Insight
Consultant for BWConsultant for BW
Lecture honoraria: SJM, Bard, Philips, Boston Scientific Lecture honoraria: SJM, Bard, Philips, Boston Scientific
Impact de l’ablation IVP Impact de l’ablation IVP sur la décompensation sur la décompensation
cardiaquecardiaqueet le risque d’AVC. Quelles et le risque d’AVC. Quelles
promesses ont été promesses ont été remplies?remplies?
Bruxelles 29 Nov 2014
AF and HF
• AF is present in 15 to 30 % of HF patients
• NYHA I: 10% of AF
• NYHA IV: 50% of AF! (Stevenson, AJC 03)• AF is associated with 1.5 to 3 fold death in
HF patients (Benjamin, Circ 98; Krahn, Am J Med, 95)
Sinus Rhythm or AF?Sinus Rhythm or AF?
Data from AFFIRM, RACE, PIAF, suggests no difference between pharmacological rate or rhythm control.However, effect of sinus rhythm without the deleterious effects of drugs was not evaluated
Data from AFFIRM, RACE, PIAF, suggests no difference between pharmacological rate or rhythm control.However, effect of sinus rhythm without the deleterious effects of drugs was not evaluated
AFFIRM Substudy (Epstein, Circulation 2004) • Sinus rhythm: 47% reduction in mortality risk• Use of antiarrhythmics: 49% increase in mortality risk• CHF: 57% increase in mortality risk
AFFIRM Substudy (Epstein, Circulation 2004) • Sinus rhythm: 47% reduction in mortality risk• Use of antiarrhythmics: 49% increase in mortality risk• CHF: 57% increase in mortality risk
Persistent AF and HF,therapeutic options
• 1- AAD (limited) and DC shocks
• 2- Rate control
– Pharmacological
– AVN ablation + CRT (P or D)
• 3- AF Ablation
AF Ablation in 86 HF patients
Male 77 (89%)
Age (years) 56±10
Persistent/Permanent AF 79 (92%)
Duration of AF (months) 80±46
Coexisting heart disease 44%
ABLATION METHOD FOR CHRONIC AF
LSPV
LIPV
RSPV
RIPV
LAA
1. PV 2. Roof
3. Inf LA-CS
4. Organising atrial activityLAA/Ant LA Septum Post LA
5. MI Line
FO
CS
Types of Atrial Electrograms TargetedTypes of Atrial Electrograms Targeted
CONTINUOUS
RAPID Local CL<REF
FRACTIONATEDRFd
RFp
Dcs
Pcs
RFd
LAA
RAA
RFd
LAA
RAA
RFd
RFp
Jais, PACE 1996
Nademanee, JACC 2004
ACTIVATION GRADIENT
Procedural Outcome
Redo Procedures 48%
Sinus rhythm (overall) 81%
Sinus rhythm without drugs 73
Duration of follow-up (months) 14±7
Major complications• Tamponade• Stroke
5%2.5%
2.5%
LV Ejection Fraction
20
30
40
50
60
70
0 1 3 6 12
Months
LV
EF
(%)
Average increase in LVEF = 21% (p<0.001)
Change in LVEF (Individual)
10
20
30
40
50
60
70
80
LVEF
(%)
Baseline Final (12±7 months)
36±7%
57±12%
11
12
13
14
0 11±7
Exercise TimeExercise Time
MonthsMonths
P=0.007P=0.007
minmin
125
130
135
140
145
0 11±7
Max Power AttainedMax Power Attained
MonthsMonths
P=0.03P=0.03
WW
Improvement Exercise Capacity In CHFImprovement Exercise Capacity In CHF
Based on 58 pts published in NEJM 2004; 351, 2373-83
25
30
35
40
45
50
55
60
65
70
0 12±7
Months
LV E
ject
ion
Frac
tion
(%)
P<0.001
P<0.001
Poor Rate Control+23±10 %
Adequate Rate Control+17±15 %
25
30
35
40
45
50
55
60
65
70
0 12±7
Months
LV E
ject
ion
Frac
tion
(%)
P<0.001
P<0.001
No concurrent heart disease+24±10 %
Concurrent heart disease+16±14 %
Rate control Heart Disease
Marked improvement (by 20% or to ≥ 55% EF)
Poor rate control: 86%Adequate rate control: 54%
No concurrent HD: 88%W/ concurrent HD: 54%
92%
Based on 58 pts published in NEJM 2004; 351, 2373-83
WORKFLOW
CardioInsight®
100 200 300 400 500 600 700-0.06-0.04-0.0200.020.04
433
100 200 300 400 500 600 700-0.05
00.05
434
100 200 300 400 500 600 700-0.05
00.050.1
424
100 200 300 400 500 600 700
-0.050
0.050.1
348
100 200 300 400 500 600 700-0.1
00.1
342
100 200 300 400 500 600 700
-0.050
0.05
341
100 200 300 400 500 600 700-0.05
00.05
340
100 200 300 400 500 600 700
-0.050
0.05
411
100 200 300 400 500 600 700
-0.1-0.05
00.05
421
100 200 300 400 500 600 700
-0.1-0.05
00.05
432
100 200 300 400 500 600 700-0.06-0.04-0.0200.020.04
433
100 200 300 400 500 600 700-0.05
00.05
434
100 200 300 400 500 600 700-0.05
00.050.1
424
100 200 300 400 500 600 700
-0.050
0.050.1
348
100 200 300 400 500 600 700-0.1
00.1
342
100 200 300 400 500 600 700
-0.050
0.05
341
100 200 300 400 500 600 700-0.05
00.05
340
100 200 300 400 500 600 700
-0.050
0.05
411
100 200 300 400 500 600 700
-0.1-0.05
00.05
421
100 200 300 400 500 600 700
-0.1-0.05
00.05
432
Patient Specific GeometryPatient Specific Geometry
252-electrode Body Vest252-electrode Body Vest
AF Interval 1
AF Interval N
Cumulative map
Effect of PVI on LV EF67/366 (18%) pts with baseline EF ≤ 50% and
“controlled” ventricular rate (<90 bpm)
0
10
20
30
40
50
60
70
80
LVEF Baseline LVEF Follow up
LV
EF
44%
57%
Gentlesk, Marchlinski et al, JCE in press
LV EF increased by > 5% in 82% patients LV EF normalized to ≥ 55% in 72% patients
70% Parox AF27% SHD
Long-term follow-up after atrial fibrillation ablation in patients with impaired left ventricular systolicfunction:
The importance of rhythm and rate control S Nedios… C Piorkowski…Andreas Bollmann… Gerhard Hindricks
Heart Rhythm2014;11:344–351
69patients, LVEF <40%PVI ± substrate ablation28 ±11 months 1.6 ± 0.7 ablation procedures45(65%) patientsIn stable sinus rhythm (SSR)
Initial improvement in LVEF is rate dependant, but not after 6 mo
Boris A. Lutomsky … Stephan WillemsEuropace (2008) 10, 593–599
70 pts paroxysmal AF MR @ 6 mo for LVEF
41+6 vs. 51+12%, P = 0.004
AF Ablation in 72 pts (40% parox)36 low EF and 36 normal (41.4+8.0 vs. 63.1+5.5%)
PABA NEJM 2008; 359: 17
1.Curative ablation of AF is feasible but difficult in patients with CHF and coexisting heart disease
2. It results in dramatic improvements in symptoms, exercise capacity and quality of life
3. This therapeutic approach is possibly the best one in first intention in patients with idiopathic dilated CMP and AF. It can be completed by CRT (D) in absence of improvement
1.Curative ablation of AF is feasible but difficult in patients with CHF and coexisting heart disease
2. It results in dramatic improvements in symptoms, exercise capacity and quality of life
3. This therapeutic approach is possibly the best one in first intention in patients with idiopathic dilated CMP and AF. It can be completed by CRT (D) in absence of improvement
Conclusion
4- Even in the context of SHD, or controlled heart rate, AF ablation can be associated with LVEF improvement
5- The LVEF improvement is more pronounced in Persistent vs Paroxysmal AF
6- This improvement is not just mediated by a decreased heart rate
4- Even in the context of SHD, or controlled heart rate, AF ablation can be associated with LVEF improvement
5- The LVEF improvement is more pronounced in Persistent vs Paroxysmal AF
6- This improvement is not just mediated by a decreased heart rate
Conclusion
Cappato et al,Circulation 2005
Rate for embolic events related to AF ablation
In the literature: 0-7%
Multicenter studies
Name N(abl) Type of AF strokes AV-Block
PABA-CHF 41 P and P 0 0
A4 53 Parox 0 0
CPVA 77 Persist 0 0
Stabile 68 P and P 1 (1.3%) 0
RAAFT 33 Parox 0 0
1. Warfarin is recommended for all patients for at least two months following an AF ablation procedure,
2. Decisions regarding the use of warfarin more than two months following ablation should be based on the patient’s risk factors for stroke and not on the presence or type of AF.
3. Discontinuation of warfarin therapy post ablation is generally not recommended in patients who have a CHADS score ≥ 2.
After ablation
755 pts ablated, 490 parox, 265 persitent, PVI + CAFE34 (5%) had previous TEs
Circ 2006;114:759-765
256 patients remained in sinus rhythm wo risk factors for stroke, anticoagulation wasdiscontinued in 203 (79%) at a median of 4 months
266 patients in sinus rhythm and had 1 risk factor, anticoagulation was discontinuedin 180 (68%) at a median of 5 months
TEs occurred in 7 of 755 patients (0.9%) within 30 daysAnd in 2 (0.3%) beyond 30 days after the procedure
A cerebral hemorrhage occurred in 2 patients (0.3%) whowere in AF and were being treated with warfarin 1 and 3months after LARFA. One patient was 70 years old and hadan INR of 3.5 and the other patient was 53 years old and hadintracranial bleeding after head trauma.
Ablation: PVI + SVCCAFE in Persistent AFIso in all
24 H Holter7 days whenever possible
3,355 patients, 2,692 (79% male, mean age 57 ± 11 years) discontinued OAT 3 to 6 months after ablation 663 (70% male, mean age 59 11 years) remained on OAT after this period CHADS2 of 1 and 2 in 723 (27%) and 347 (13%) Off-OAT 261 (39%) and 247 (37%) On-OAT group patients, respectively.
Incidence of Late Thromboembolic Events AfterCatheter Ablation of Atrial Fibrillation
Atsuhiko Yagishita, MD; Yoshihide Takahashi, MD; Atsushi Takahashi, MD; Akira Fujii, MD;Shigeki Kusa, MD; Tadashi Fujino, MD, PhD; Toshihiro Nozato, MD, PhD;Taishi Kuwahara, MD; Kenzo Hirao, MD, PhD; Mitsuaki Isobe, MD, PhD
524 ptsParox 69%Persistent 31%FU 44± 13 mo
Botto, JCE; Vol. 20, pp. 241-248, March 2009
Botto, JCE; Vol. 20, pp. 241-248, March 2009)
Discontinuing anticoagulation following successful atrialfibrillation ablation in patients with prior strokes
Roger A. Winkle & R. Hardwin Mead & Gregory Engel &Melissa H. Kong & Rob A. Patrawala
J Interv Card Electrophysiol (2013) 38:147–153
108 patients with a history of prior thromboembolic CVA/TIA
Ablation Protocol and FU
• PVI and roof line in all
• CAFE in persistent and long standing
• Mitral and CT isthmus if needed
• Interrupted Warfarin
• 7/21 days Holter monitoring
• OAC interrupted @ 7,3 mo
• follow-up after discontinuation of OAC averaged 2.2±1.3 (median=1.8) years.
Discontinuing anticoagulation following successful atrialfibrillation ablation in patients with prior strokes
Roger A. Winkle & R. Hardwin Mead & Gregory Engel &Melissa H. Kong & Rob A. Patrawala
565 AF AblationsFU 40 mo27 pts (4,8%) TE events or death9 death, 9 strokes, 6 TIA
Cauchemez et al, JCE 2004
Cauchemez et al, JCE 2004