Stepwise Management of Persistant Atrial Fibrillation

“Case Presentation”

Salah Atta, MD Consultant Cardiac Electrophysiology

Saud Albabtain Crdiac Center, Al-Dammam, KSAAss.Prof. Cardiology, Assiut Univ. Egypt

ESC & SHA Congress, Al-Dammam, 9/11/ 2013.

Learning Objectives:

• Outline major principles of AF management

• Ensure the appropriate selection of rhythm versus

rate control strategy

• Define the position of ablation therapy in the

management of AF.

• Clarify confusions about post ablation

anticoagulation.

-A 40 years old female patient, diabetic, hypertensive, referred after 1ry management in another hospital with symptomatic atrial fibrillation of one week duration.

Symptoms: SOB, fatiguability causing her discomfort with daily activity.

B.W.: 70 kg, Height 160 cm

BP: 135/75, HR 80/min, irregular, compensated.

Normal echocardiographic findings, LA: 3.8 cm.

Normal Renal and hepatic functions, normal thyroid functions.

-Patient came with these medications for a week:, Atenolol 50 mg od, Co_renitic 20/12.5 mg, Amlodipine 5 mg, Digoxin tab: 0.25 mg, Dabigatran 150 mg twice daily mg in addition to oral hypoglycaemic medication.

Is there any thing more to be done?

• The patient is young, DM, HTN, with normal heart, presenting with persistent AF, already controlled AF rate, haemodynamically stable, non disabling symptoms, not in heart failure, already anticoagulated for one week.

Objectives of Clinical Management of patients with AF :

1- Prevention of thromboembolism.3-Symptom relief . 2-Optimal management of concomitant cardiovascular disease.4. Rate Control.5.Correction of the rhythm disturbance.

To anticoagulate or not!?

What is this patient annual risk of thromboembolism?

Balancing the Risk of Stroke and the risk of bleeding

HASBLED score = 0, CHA2DS2VASC2 = 3OAC confer greater benefits than risks for this patient

2012 Focused Update of ESC Guidelines

Objectives of Clinical Management of patients with AF :

1- Prevention of thromboembolism.3-Symptom relief . 2-Optimal management of concomitant cardiovascular disease.4. Rate Control.5.Correction of the rhythm disturbance.

How to assess patient‘s AF- related symptoms!?

•

Rate control or rhythm control

1. Age of the patient.

2. Symptoms and quality of life.3. AF type (paroxysmal, persistent, long-lasting persistent).4. Underlying cardiovascular disease and comorbidities.5. Atrial remodeling and risk of progression of AF.

Rhythm control was decided

-DC cardioversion to sinus rhythm by synchronized biphasic 120 J after TEE excluded LA thrombi and the patient was maitained on AC plus medical treatment with Beta blockers and propaphenone to maintain sinus rhythm.

Follow Up• During follow up, the patient was still

symptomatic with recurrent palpitations shortness of breath on exertion and fatigue (EHRA III) despite medical treatment (Propaphenone, Sotalol).

• Myocardial perfusion imaging ruled out reversible or non reversible ischaemia.

• 24 hours Holter proved frequent recurrences of the AF throughout the day.

When to consider ablation therapy for AF?

Older 2010 ESC Recommendations

Older 2010 ESC Recommendations

2012 Focused Update of ESC Guidelines

The procedure:

The left atrium was catheterized via a trans-septal puncture.

Selective pulmonary venography.

The image of each vein was continuously displayed on a server screen throughout the procedure.

Precautions to reduce risk of complications:

• TEE performed (2-5 days before ablation).

• Bridging with heparin to maintain anticoagulation in the periablation period.

• Intracardiac Echo to guide transseptal puncture and RF lesions.

• 3D mapping guided RF ablation and using oesophageal temp. probe.

Transeptal Puncture

LASSO

Monitoring RF application

Catheter Based Pulmonary Vein Isolation – The Goal

R superiorPV

R inferiorPV

L superiorPV

L inferiorPV

Complete Isolation of Each Pulmonary Vein Orifice

Follow-Up

Patient was discharged home the day after ablation.

Follow-up was scheduled after ablation with repeated Holter monitoring.

She was free of recurrence of AF for two years.

Now, can we stop her anticoagulation, otherwise what is the benefit of ablation?!

Long Term Outcome• AF is a chronic progressive disease

specially in patients at risk for stroke and ablation is aimed at improving patient’s symptoms.

• One year freedom of AF: around 80% • At 5 years: it is around 52%.

Post Ablation Anticoagulation