AF ablation is a waste of time and money

Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest Hospital

AF ablation is a waste of time and money:

(you must be joking!)

Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest Hospital

A recap of what we’ve learnt this morning….

AF kills you (slowly)….

AF makes you miserable….

AF costs megabucks….

2.4% of the total NHS budget

Conventional treatments limited efficacy

Drugs only work in 1 in 3 patients

Not only are drugs potentially ineffective but…..

• They often cause unacceptable side effects

• Discontinuation rates due to Adverse Effects:

• CTAF: 18% Amio, 11% Sotalol

• AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide

• They may increase mortality

• SPAF: esp. in heart failure

• AFFIRM: AAD associated with mortality (p=0.0005)

Dronedarone isn’t the answer….

• Mild antiarrhythmic action

• AF recurrence at 1 year: 64% vs 75% for Placebo

• << Amiodarone (free from AF at 6 mo: 37% vs 58%)

• Increased mortality in Heart Failure (ANDROMEDA)

• Only approved by the NICE with reservations

….and neither is cardioversion

Finally, a cure is in sight!......

Culprit: triggers in pulmonary veins

Treatment: Pulmonary Vein Isolation

The procedure works…..

Current success rates 80%

in long standing persistent AF too..

N Redo AAD therapy Results Complications

HaissaguerreJCE 2005

60 1/2 Stopped at ablation

95% at 11 months

2 Tamponades

OralNEJM 2006

77 1/3 Amio 6/52 pre & 3/12 post

77% at 1 year

0

PostchCirc 2008

88 1/2 Stopped at ablation

81% at 20 months

2 Tamponades1 TIA

LoJCE 2009

87 1/4 AAD for 2/12 post

79% at 21 months

1 Tamponade

It’s clearly better than drug therapy

AF ablation has evolved rapidly…

• Success rates have doubled

• Paroxysmal AF: 40-50% to 80-90%

• Persistent AF: 30-40% to 70-80%

• Procedure times have halved

• From 4-6 hours to 2-3 hours

• Complication rates have halved: 4% to 2%

Current technology has improved accuracy

The last thing we now need is a party pooper!

Ablation80% chance of

cureOne-stop solution

Drugs30% efficacy

Life long suffering

If you always do what you always did…you’ll always get what you’ve always

got

Yes, AF ablation costs money…

• 100,000 AF cases a year Median 1.5 procedures

• £4000 per ablation

• Total cost: half a billion pounds

But where would you rather spend this money?

• ? Iraq War: £ 4.5 billion (Mar 2006)

• ? Olympics: £9.8 billion

• ? NHS IT project: £15 billion

• ? Bank Bailout £850 billion

Upfront costs outweighed by subsequent savings…

• Costs of recurrent hospital admissions

• Electrical cardioversions

• Absences from work

• Costs of lifelong drug therapy

• Regular INR tests

• Decreased risk of the serious AF sequalae

• Stroke

• Heart Failure

Measures to make ablation more cost effective

1. Careful patient selection: ablation not offered

• Very long standing Persistent AF (>3 years)

• Very large LA (>5.5 cm)

• Morbid Obesity (BMI >40)

• Age >80 years

• Significant co-morbidity

Measures to make ablation more cost effective

2. Individualised ablation strategy:

Improve single procedure success rates

Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010

Finally...

What would you want?!