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Atrial Fibrillation: Pearls and Pitfalls

Christopher R. Cole, M.D., FHRS

Colorado Springs Cardiologists

Director of Electrophysiology Lab

Penrose-St. Francis Hospital

Colorado Springs, Colorado

Disclosures

• Speakers Panel: Medtronic, Boston Scientific, St. Jude Medical, Pfizer, BMS

• Research Support: St. Jude Medical, Boston Scientific, Medtronic, Atricure

Atrial Fibrillation – The Problem

• Over 5 million people worldwide are affected by atrial fibrillation.

• Over 3 million in the US alone. • Prevalence increases with age:

– 4.8 % in the 70-79 age group – 8.8% in the 80-89 age group

• Lifetime Risk for Any Afib 1:4 M, 1:5 F

Atrial Fibrillation – The Problem

1. Increased Stroke Risk 2. Rapid, Irregular Heart Beat

May lead to congestive heart failure (CHF) 3. Symptoms – variable 4. Potential long term risks including

increased mortality

Atrial Fibrillation – Definitions

1. Paroxysmal – Episode terminates spontaneously

2. Persistent – Lasting greater than 7 days or requires chemical or electrical cardioversion

3. Long-Standing Persistent – Continuous AF greater than one year

4. Permanent – A decision has been made not to pursue a rhythm control strategy

Clinical Pearl # 1

Not All That Palpitates is

Fibrillation First Step - Order a Monitor

Question # 1

All Paroxysmal Atrial Fibrillation eventually becomes Permanent Atrial Fibrillation. A) True B) False

Drugs

Ablations

Atrial Fibrillation- Treatments

Devices

Surgery

Adjunctive Therapies

Drug Treatment Goals

• Reduce Stroke Risk • Control Ventricular Rate • Restore Sinus Rhythm


• Reduce Stroke Risk – Warfarin – Aspirin/clopidogrel – Not as effective – NOACs

• Control Ventricular Rate • Restore Sinus Rhythm

CHADS-VASc

For all CHADS2 scores of 0 or 1 add:

– 1 point for Vascular Disease (CAD, PVD)

– 1 point for Age 65-75 – 1 point for Sex - female gender

If the score is still 0 then the patient is truly low risk

Novel Oral Anticoagulants (NOACs)

Pradaxa (dabigatran) – Direct Thrombin Inhibitor

Xarelto (rivaroxiban) – Factor Xa inhibitor Eliquis (apixaban) – Factor Xa inhibitor Savaysa (edoxaban) – Factor Xa inhibitor


• Reduce Stroke Risk • Control Ventricular Rate

– Beta-Blockers – Calcium Channel Blockers – Digoxin – (amiodarone, dronedarone) – (Ablate and Pace)

• Restore Sinus Rhythm



– Antiarrhythmic Medications: • Flecainide, Propafenone • Sotalol • Amiodarone, Dronedarone • Dofetalide

Rate vs. Rhythm

Mortality in AFFIRM

Circulation 2004; 109:1509 -1513

On Treatment Analysis P value Hazard

Ratio Lower

Confidence Limit

Upper Confidence

Limit

Maintenance of Sinus Rhythm

<0.0001

0.53

0.39

0.72

Warfarin

Use

<0.0001

0.50

0.37

0.69

Presenter

Presentation Notes

But if AAD was continued this benefit was lost.

ATHENA Reduction in Risk of Stroke

Connolly Circ 2009

Presenter

Presentation Notes

Post-Hoc analysis. The drug was actually approved to reduce time to hospitalization

Post-Ablation: Stroke

n=37,908

Bunch J Cardiovasc Electrophysiol, March 15, 2011

Presenter

Presentation Notes

This slide shows the long-term stroke risk. The black line represents the atrial fibrillation ablation group. The blue line represents the group without atrial fibrillation. The green line represents the medically treated atrial fibrillation group. 这张幻灯片显示了长期的中风风险。黑线代表的是经过房颤消融的患者. 蓝线代表的是没有房颤的患者. 绿线代表的是药物治疗的房颤的患者. Zhè zhāng huàndēng piàn xiǎnshì le chángqí de zhòngfēng fēngxiǎn. Hēi xiàn dàibiǎo de shì jīngguò fáng chàn xiāoróng de huànzhě. Lán xiàn dàibiǎo de shì méiyǒu fáng chàn de huànzhě. Lǜ xiàn dàibiǎo de shì yàowù zhìliáo de fáng chàn de huànzhě. You can see that the stroke risk for the ablation group and the group without atrial fibrillation was very low. 你可以看到，房颤消融组和没有房颤组的中风风险都非常低. Nǐ kěyǐ kàn dào, fáng chàn xiāoróng zǔ hé méiyǒu fáng chàn zǔ de zhòngfēng fēngxiǎn dōu fēicháng dī. The medically treated atrial fibrillation patients had a statistically significant much higher stroke risk. 但是, 药物治疗的房颤组的中风风险非常高. Dànshì, yàowù zhìliáo de fáng chàn zǔ de zhòngfēng fēngxiǎn fēicháng gāo.

Post-Afib Ablation: Mortality

n=37,908

Bunch J Cardiovasc Electrophysiol, March 15, 2011

Presenter

Presentation Notes

This slide shows the long-term mortality risk. 这张幻灯片显示了长期的死亡风险。 Zhè zhāng huàndēng piàn xiǎnshì le chángqí de sǐwáng fēngxiǎn. The black line represents the atrial fibrillation ablation group. 黑线代表的是经过房颤消融的患者. Hēi xiàn dàibiǎo de shì jīngguò fáng chàn xiāoróng de huànzhě. The blue line represents the group without atrial fibrillation. 蓝线代表的是没有房颤的患者. Lán xiàn dàibiǎo de shì méiyǒu fáng chàn de huànzhě. The green line represents the medically treated atrial fibrillation group. 绿线代表的是药物治疗的房颤的患者. Lǜ xiàn dàibiǎo de shì yàowù zhìliáo de fáng chàn de huànzhě. You can see that the mortality risk for the ablation group and the group without atrial fibrillation was very low. 你可以看到，经过房颤消融的患者和没有房颤的患者的死亡风险都非常低. Nǐ kěyǐ kàn dào, jīngguò fáng chàn xiāoróng de huànzhě hé méiyǒu fáng chàn de huànzhě de sǐwáng fēngxiǎn dōu fēicháng dī. The medically treated atrial fibrillation patients had a statistically significant much higher mortality risk. 但是, 药物治疗的房颤患者的死亡风险非常高. Dànshì, yàowù zhìliáo de fáng chàn huànzhě de sǐwáng fēngxiǎn fēicháng gāo.

Clinical Pearl # 2

Calculate a CHADS-Vasc Score on all your patients with

Atrial Fibrillation

Question # 2

A 75 yo woman with Afib, diabetes and a TIA has no history of heart failure, peripheral vascular disease or heart failure. Her CHADS2-Vasc score is: A) 2 B) 3 C) 4 D) 5 E) 6


• Obstructive Sleep Apnea (OSA) • Diet

– Obesity – Coffee – Alcohol – Fish Oil

• “The rest of the body” – Inflammation – Smoking

Adverse Effects of Untreated Obstructive Sleep Apnea (OSA)

• Ventricular Arrhythmias • Heart Attack • Heart Failure • Stroke • Sexual Dysfunction • Diabetes • Obesity • Depression • Death

OSA and Prevalence of Cardiac Arrhythmias in the Sleep Heart Health Study

Mehra et al. AJRCCM 2006

OSA in Patients with Atrial Fibrillation

Gami et al. Circulation 2004

Can Treatment of OSA prevent/improve AF outcomes?

Maybe and Yes

Presenter

Presentation Notes

The question becomes…can teatment of OSA prevent and/or improve outcomes in AF? I think the answer is maybe and yes.

Recurrence of AF at 12 months Post-Cardioversion

Kangala et al. Circulation 2003

12 m

onth

recu

rrenc

e of

AF,

%

Control Treated Untreated OSA OSA

Kanagala Circulation 2003

Presenter

Presentation Notes

The treated OSA group had a better outcome than the control group – perhaps because there were untreated OSA pts in this group. Pts without reoccurance were more than 3 times likely to have used effective CPAP.

Treatment of OSA improves success rates of PVI

• 52 pts with OSA • 28 (53%) using CPAP • At 26 months 72% CPAP vs. 63% non-

CPAP were free from AF (p=0.005) • CPAP group outcomes similar to age and

sex matched controls

Anter JACC 2012

Presenter

Presentation Notes

ACC abstract - Treatment of Obstructive Sleep Apnea Reduces The Risk of Atrial Fibrillation Recurrence Following Catheter AblationMarch 2012Elad Anter, MD, et alJACChttp://content.onlinejacc.org/cgi/content/full/59/13_Suppl_S/E612?maxtoshow=&hits=7&RESULTFORMAT=&title=sleep+apnea&andorexacttitle=or&titleabstract=sleep+apnea&andorexacttitleabs=and&fulltext=sleep+apnea&andorexactfulltext=and&searchid=1&usestrictdates=yes&resourcetype=HWCIT&ct Background The association between obstructive sleep apnea (OSA) and atrial fibrillation (AF) is well established, and OSA has been also implicated in greater recurrence rates after catheter ablation. However, whether therapy of OSA reduces the risk of AF recurrence following ablation is still unknown. The aim of this study was to investigate whether treatment of OSA reduces the risk of AF recurrence following ablation. Methods We studied 426 consecutive patients with paroxysmal AF referred for index circumferential pulmonary vein isolation (PVI) between July 2006 and July 2010. Diagnosis of OSA was based on a positive polysomnography study defined by the apnea hypopnea index >15 per hour, and >80% of all apnea/hypopnea events had to be obstructive. Patients with OSA were divided by CPAP use. All patients in the CPAP group had been treated with a nocturnal nasal CPAP therapy for a minimum of 3 months before the procedure and continued treatment for the duration of the follow-up period. All patients underwent PVI with demonstration of entrance and exit block. The mean follow-up period was 26 months. Recurrence of AF was determined by cardiac event monitoring at the first 3 months, and then by scheduled office electrocardiograms and patient's symptoms. Results Fifty two patients (12.2%) in this series had OSA. Among these patients, 28 (53%) were treated with continuous positive airway pressure (CPAP) while 24 (46%) were not. At the end of the follow-up period (26±18 months), 72% of the CPAP and 62% of the non-CPAP group were free of AF (P=0.005). Treatment with CPAP was an independent predictor of improved outcome, as multivariable analysis showed no significant difference between the groups in regard to the presence of hypertension, diabetes, basal metabolic index, left atrial size, or therapy with antiarrhythmic drugs. Moreover, patients with treated OSA experienced AF recurrence rates that was similar to a matched control group of patients without OSA (72% vs. 70%, P=ns). Conclusions Treatment of OSA with CPAP improves the success rate of catheter ablation and therefore merits special consideration when evaluating patients for AF ablation Why does it improve outcomes? It may be that there is less reconnection of the veins in treated OSA


• Obstructive Sleep Apnea • Diet


• “The rest of the body” – Inflammation – Kidneys

Obesity

BMI = 4% AF risk increase • Increased Risk of Sleep Apnea • Increase in LA volume and pressures • Increase in Pulmonary Pressures • Decreases in Atrial ERPs • Better QoL post-ablation • Weight loss reduces AF

Wang JAMA 2004 Munger JACC 2012 Mohanty Heart Rhythm 2011

Presenter

Presentation Notes

Each increase in BMI by 1 unit increases the risk of development of af by 4% in the Framingham data. There is a little bit of good news. In a study by Mohanty the Qol scale post-ablation was better in those with higher BMI

Coffee and AF

• Popular opinion is to avoid coffee to prevent AF

• However… No evidence to support this perception

• In fact, there may be beneficial effects

• This does not apply to “Energy drinks”

Glatter; Curr Treat Options Cardiovasc Med. 2012 Freedman NEJM 2012

Presenter

Presentation Notes

Popular opinion is to avoid coffee if you have arrhythmias and in fact some people just don’t like the way coffee makes them feel and they should avoid it. Recent NEJM study 5/12 from NIH by Freedman showed a mortality benefit to coffee. Does not apply to “energy drink” which are loaded with sugar and other stimulants. Give example of woman who had VF arrest due to Red Bull

Alcohol and AF

• Moderate use decreases CAD • Any amount can cause atrial and

ventricular arrhythmias • Classic “Holiday Heart” • Heavy Use Cardiomyopathy AF • Increased sympathetic activity and

decreased vagal modulation • Decreased HRV

Koskinen Br Heart J 1987 Ettinger Am Heart J 1978 Thornton Lancet 1984

Presenter

Presentation Notes

We’ve long know that heavy alcohol use (defined as >4 drinks/day) increases atrial fibrillation. Even in people who don’t drink regularly, heavy bing drinking can cause the classic “holiday heart” Long term heavy use can lead to a cardiomyopathy which can lead to atrial fibrillation. Alcohol also affects the autonomic nervous system … What has previously be less well described is moderate use of alcohol on atrial fibrillation.

Alcohol and AF – Meta Analysis

• 14 Studies (130,820 participants and 7,558 cases)

• Significant increase AF with heavy intake (pooled estimate of 1.35-2.24)

• Linear dose response was found even with moderate intake

Kodama JACC 2011

Presenter

Presentation Notes

Between 1974 and 2009 1754 citations reviewed Case controlled and cohort design Significant increase with heavy alcohol. Ho hum we all know that. What was interesting in this analysis is that they found a linear dose response even with moderate use.

Log OR/RR Regression Model for Daily Alcohol Use

Kodama JACC 2011

Presenter

Presentation Notes

Solid line is a log odds ratio or relative risk and it’s corresponding 95% confidence intervals based on a cubic spline regression model. Importantly there was not a U shape curve such as you would find with alcohol and coronary disease – explain. Nor was there a J-shaped curve suggesting there is a point below which daily alcohol use does not promote atrial fibrillation. The solid curve and its accompanying area indicate the log odds ratio or relative risk (OR/RR) and its corresponding 95% confidence interval based on a restricted cubic spline regression model with knots at 8, 22.5, and 33.1 g/day of alcohol consumption. This model did not significantly improve the fit compared with the linear regression model expressed by the dotted line. The area of each data point is proportional to its statistical weight.

Log OR/RR Regression Model for Daily Alcohol Use

Kodama JACC 2011

The relationship between daily alcohol consumption and the risk of AF was explained by a linear dose-response model, suggesting that not consuming alcohol at all is the most favorable behavior for avoiding AF rather than moderate alcohol consumption.

Fish Oil (PUFAs*)

• Jury is still out • Animal data demonstrates atrial

remodeling and prevention of AF • Human data showing prolongation of atrial

ERP, reduction in inducibility of AF, improvement in atrial function post-cardioversion

• 3 negative and 3 positive RCT *Prescription-Grade Omega-3 fatty acids Time to fish or cut bait ?

Olshansky Heart Rhythm April 2012


• Obstructive Sleep Apnea • Diet


• “The rest of the body” – Inflammation – Smoking

Inflammation and AF • CRP levels increased in AF • Higher CRP levels associated with failure of CV

and recurrence of AF after CV • Higher CRP levels maybe associated with

increased thromboembolic risk with AF • Simvastatin attuatuates electrical remodeling in

dog model of AF • Statin Rx shown to reduce risk of AF recurrence

after CV • Colchicine reduces AF post-op

Presenter

Presentation Notes

Not as much interest in this recently. I think partly because we don’t have good treatments for inflammation. However, there is clearly a link between inflammation and AF and there may be some good statgies to help reduce AF.

Smoking and AF

Chamberlain Heart Rhythm 2011

Presenter

Presentation Notes

Increased risk of af with smoking

Summary Adjunctive Therapies for AF

• Low Threshold for Sleep Study • Encourage Weight Loss • Discuss Alcohol Use • Hyperlipidemia Statin • Smoking cessation • Consider Fish Oil Supplements • Have Another Cup of Coffee!

Presenter

Presentation Notes

A lot of these things are just being a good doctor and taking care of your patient. Low threshold for sleep study. I wnet and got a sleep study myself and got hooked up to the CPAP just so I could tell my patients about it. It’s not too bad. If they have any signs of sleep apnea, fatigue, obesity, snoring I will send my patients for a study. Our positive rate is about 90% of people with AF that we send! Encourage weight loss. I’ve even sent a few patients with af for bariatic surgery and it has helped them tremendously. Discuss alcohol use. I’ll ask my patient who are heavy drinkers why they are willing to undergo a $90k procedure where they could die but they’re not will to stop or reduce their drinking patterns. I’ve had patients quit drinking and have complete resolution of their AF.

Clinical Pearl # 3

Even Thin people Can have

Sleep Apnea

Consider a Sleep Study in all your patients with Afib

Question # 3

When seeing a patient with afib consider recommending all of the following except: A) Reducing or Stopping Alcohol B) Avoiding all caffeine, including chocolate C) Encouraging Weight Loss D) Screening for Sleep Apnea E) Checking TSH and electrolytes

Devices

Amplatzer Cardiac Plug (ACP)

WATCHMAN

Lariat Device

Left Atrial Appendage Occlusion

• Majority of blood clots form in the LAA

• Trans-septal placement of device to occlude LAA

• Shown to be as effective as warfarin in preventing strokes

WATCHMAN LAA Closure Device in situ

3000838-18

Ablations

Presenter

Presentation Notes

Correlation of spiral CT and pulmonary angiogram. These are both pre-ablation. Note that there is a “stenosis” in the proximal part of the vein.

Wavelet Hypothesis

• Multiple wavelet hypothesis – Moe and Abildskov 1959

• “…multiple independent reentrant wavelets, to maintain fibrillation must be…changing in position, shape, size and number with each successive excitation”

• Confirmed by detailed mapping in animals and humans

Moe Am Heart J 1959

Maze Procedure

• Based on wavelet hypothesis of atrial fibrillation

• Open heart bypass procedure

• Cut atrium to small segments that cannot maintain fib

• Often done in conjunction with another open-heart procedure such as mitral valve repair

• 50-80% successful

Cox J Thorac Cardiovasc Surgery 1991

Triggers of Atrial Fibrillation

• First proposed by Winterberg in 1906

• Haïssaguerre 1998 mapping during linear lesions

• Isolated areas of rapid focal firing (200-300 bpm) coming primarily from the pulmonary veins

Haïssaguerre NEJM 1998 Chen, Circulation 1999

New Paradigm for Afib

Pulmonary Vein Triggers

Substrate

Electrical Remodeling

Multiple Wavelets/Rotors

Circular Mapping Catheters

Atrial Septum Transeptal

Catheter

Transeptal Access of the Left Atrium

Mapping at ostium of PV

Final map

Cryoballoon Catheter • Two balloons diameters:

– 23mm & 28mm • Double balloon safety

system • Bi-directional deflection • Over-the-wire system

Metzner Circ Arrhythmia Electrophysiology 2013

Occlusion of the PV

Complete LSPV occlusion with no leak of contrast into the atrium (Arctic Front™ 28 mm)

Courtesy of Jurgen Vogt, MD.

Presenter

Presentation Notes

To add additional multimedia to your presentation, please go to (copy the URL and paste it into your browser) the following web address: http://www.cryocath.com/en/20.document.center/20.1.4.ep.video.photo.asp “Arctic Front” video This fluoroscopic view nicely demonstrates Arctic Front in the LSPV, with complete occlusion as verified by 50/50 contrast saline injection just prior to ablation Freezor® MAX may be needed to touch up gaps where gaps occur Courtesy of J. Vogt, MD.

Ablation vs. AAD

JACC 48 (11), pp. 2340-2347, 2006

http://www.scopus.com.scopeesprx.elsevier.com/source/sourceInfo.url?sourceId=22401&origin=resultslist





Success Rates by Type of AF Type of AF Success w/o

AADs Success with AADs

Overall Success

Paroxysmal 75 (65-83) 9 (0.2-15) 84 (79.7-88.6) Persistent 65 (52-72) 10 (0.8-15) 75 (66-80) Long-lasting 63 (53-71) 8 (0.9-16) 71 (67-76)

Cappato, Circ. Arrhythm. Electrophysiol. 2009;2:349

AV Node Ablation (Ablate & Pace)

• Ablation of AV node controls rapid heart rate

• Still require anticoagulation • Patient becomes pacemaker dependent • Option in symptomatic, elderly individuals

who have failed medical management • Consider Biventricular pacemaker in

patients with EF <50%

Objective Benefits of Catheter Ablation of AV Nodal Conduction and Permanent

Pacemaker Implantation

Rodriguez LM. Am J Cardiol 1993;72:1137-1141.

A Left ventricular ejection fraction (%)

B Left ventricular end systolic diameter (mm)

70

60

50

40

30

20 Before After

LVEF

(%)

mean 54 + 7

p < 0.001

mean 43 + 8

55

50

45

35

30

20 Before After

LVES

D (m

m)

mean 34 + 5

p < 0.003

mean 40 + 5

40

25

Ablation Summary • Pulmonary Vein Isolation (PVI)

– Symptomatic individuals who have failed medical therapy or who do not desire to take long-term meds

• AV Node Ablation (rate control) – Symptomatic elderly or frail patients who have

failed rate control (<110 bpm at rest) • Hybrid procedure – Consider in symptomatic

patients with permanent afib and enlarged left atrium

Question # 4

An ideal patient for catheter ablation would have all of the following characteristics except: A) Symptomatic Atrial Fibrillation B) Left Atrial Volume Index > 50 C) No significant heart valve disease D) Failure of Medical treatment E) Treated Sleep Apnea

Clinical Pearl # 4

Patients don’t have to live with

Atrial Fibrillation!

THANK YOU!

Additional Slides

Unadjusted Odds Ratios for OSA in Patients with Atrial Fibrillation


Presenter

Presentation Notes

If we look at the risk factors for OSA in this population you can see the usual suspects; male gender slightly higher risk, body mass index – the heavier you are the more likely your risk for afib, we’ll look at that more later, Hypertension, diabetes, both risk factors for afib. Not as much in this study with CAD and CHF. Pts with afib twice as likely to have OSA, we just saw that on the previous page. Now if we adjust for these factors statistically… (change slide)

Adjusted Odds Ratios for Association between OSA and Atrial Fibrillation


Presenter

Presentation Notes

You might think that afib is just a secondary marker for other risk factors such as HTN, obesity. However, even after adjusting for these factors AF is still twice as likely to be predictive of OSA. We see that Afib comes out as the strongest predictor of afib. BMI is the next strongest.

OSA Causes Interatrial Conduction Delay (ICD)

• 250 pts undergoing sleep study • No history of AF or heart disease • ICD defined as P wave �> 110 msec • ICD strongly correlated with AHI (1.54 per

10/hour)

Maeno Circulation 2010

Presenter

Presentation Notes

1) Obstructive Sleep Apnea causes Interatrial Conduction DelayNovember, 2010Ken-ichi Maeno, et alCirculation Journalhttp://circ.ahajournals.org/cgi/content/meeting_abstract/122/21_MeetingAbstracts/A20638 Background:Prolonged P wave duration, which means interatrial conduction delay (ICD), is a marker of left atrial abnormality and reported as a potent precursor of atrial fibrillation (AF). On the other hand, several studies showed obstructive sleep apnea (OSA) was associated with AF. We assessed the hypothesis that OSA causes ICD. Methods:Consecutive 250 subjects who underwent overnight polysomnography under the suspicion of OSA, with normal sinus rhythm, no history of AF or ischemic heart disease, or no evidence of heart failure were enrolled. P wave duration was determined as the mean duration of three consecutive beats in lead II from the digitally-stored electrocardiogram. An ICD defined by New York Heart Association criteria as a P wave duration >/=110 ms. Subjects were classified into two groups; ICD group and control group, and logistic regression analysis was performed to determine the related factors for ICD. Results:ICD was observed in 93 (37 %). P wave duration was correlated with apnea hypopnea index (AHI; r=0.56, p<0.001). Compared with control group, ICD group was significantly older (51±13 vs 55±13 year-old, p=0.017), revealed higher level of body mass index (25.3±3.9 vs 27.2±4.0, p<0.001), AHI (26.5±21.1 vs 48.1±20.6 /hr, p<0.001), percentage of SO2<90% during sleep (11.3±17.9 vs 29.4±29.5 %, P<0.001), and included more number of those with hypertension (32 vs 56 %, p<0.001) and male gender (85 vs 97 %, p=0.009). In multivariate logistic regression analysis including age, gender, body mass index, hypertension, diabetes, dyslipidemia, uric acid, C-reactive protein, AHI (per 10 /hr) and percentage of desaturation time during sleep as an independent variables, age (oddw ratio 1.04, p=0.008) and AHI (odds ratio 1.54, p<0.001) were significantly associated with ICD. Conclusions:Severity of OSA was significantly associated with delayed interatrial conduction time. These suggest that OSA might lead to progression in atrial remodeling as a substrate for AF.

Presence of OSA predicts Reconnection of PVs

Sauer Heart Rhythm 2006

n=424

Presenter

Presentation Notes

Primary prevention t\studies to see if treating OSA can prevent Afib have not been done and probably will not be done. This is not such a problem for us because our patients already have afib when they come to us.

Why is OSA associated with AF?

• (Not all studies show a correlation) • Swings in Intrathoracic pressure can cause

stretch and enlargement of the atria and PVs • Instability of Autonomic tone; Vagalitic

Bradycardia • Surges in Sympathetic Neural Activity (SNA)

Triggers (Including Non-PV triggers) • Association with Obesity • Increase in Systemic Inflammation with OSA

Fish Oil (PUFAs*)

• Differences may be dose dependent • Most trial had doses between 4-8 g/d • Positive trials used PUFAs in conjunction

with antiarrhythmic drugs • May be more beneficial in persistent AF • Low-cost, low-risk • Larger Trials are underway

*Prescription-Grade Omega-3 fatty acids Time to fish or cut bait ? Olshansky Heart Rhythm April 2012

Presenter

Presentation Notes

Differences may be dose dependent.

Coffee and Arrhythmias

Kl

Presenter

Presentation Notes

I think this may go against conventional wisdom but it is important for your patients to at least know the data and make their own choices.

Smoking and AF • Smoking increases inflammation • 15,000 pts ARIC study – 15 yrs • Former/Current smokers OR 1.32 / 2.05 • Risk increases with increasing cigarette years • Supports the finding of 2 other cohort studies

(Framingham and Rotterdam Study) • Two previous cohort studies did not find a link

but did not account for former smokers

Chamberlain Heart Rhythm 2011

Presenter

Presentation Notes

Increased risk of af with smoking

Statin Use May reduce AFib

Siu et al, 2003

AF and HTN • Prevalence of AF and HTN very common • Prevalence of both increase with age • ACE inhibitors appear to reduce the risk of

developing AF in patients with HTN compared to CCB by approx 15%

• HTN results in LVH and LA enlargement • Atrial stretch and fibrosis may be substrate for

AF mediated by angiotensin II

Rx of HTN and Incidence of AF

L’Allier et al, 2004

Afib Ablation results are worse in lower GFR

Naruse Heart Rhtyhm 2011

Alcohol and Vagal Tone

• 223 pts presenting for EPS/Ablation – (113 PAF 90 SVT)

• ETOH use as trigger – OR 4.42 (1.35-14.44) more likely in PAF

• Vagal activity prior to episode – OR 2.02 (1.02-4.0) more likely prior to PAF

Mandvam AJC 2012

Presenter

Presentation Notes

Am J Cardiol. 2012 Aug 1;110(3):364-8. Epub 2012 Apr 20.Alcohol and vagal tone as triggers for paroxysmal atrial fibrillation.Mandyam MC, Vedantham V, Scheinman MM, Tseng ZH, Badhwar N, Lee BK, Lee RJ, Gerstenfeld EP, Olgin JE, Marcus GM.SourceDivision of Cardiology, Electrophysiology Section, University of California, San Francisco, San Francisco, CA, USA.AbstractAlcohol and vagal activity may be important triggers for paroxysmal atrial fibrillation (PAF), but it remains unknown if these associations occur more often than would be expected by chance alone because of the lack of a comparator group in previous studies. We compared self-reported frequency of these triggers in patients with PAF to those with other supraventricular tachycardias (SVTs). Consecutive consenting patients presenting for electrophysiology procedures at a single university medical center underwent a structured interview regarding arrhythmia triggers. Two hundred twenty-three patients with a documented arrhythmia (133 with PAF and 90 with SVT) completed the survey. After multivariable adjustment, patients with PAF had a 4.42 greater odds (95% confidence interval [CI] 1.35 to 14.44) of reporting alcohol consumption (p = 0.014) and a 2.02 greater odds (95% CI 1.02 to 4.00) of reporting vagal activity (p = 0.044) as an arrhythmia trigger compared to patients with SVT. In patients with PAF, drinking primarily beer was associated with alcohol as a trigger (odds ratio [OR] 4.49, 95% CI 1.41 to 14.28, p = 0.011), whereas younger age (OR 0.68, 95% CI 0.49 to 0.95, p = 0.022) and a family history of AF (OR 5.73, 95% CI 1.21 to 27.23, p = 0.028) each were independently associated with having vagal activity provoke an episode. Patients with PAF and alcohol triggers were more likely to have vagal triggers (OR 10.32, 95% CI 1.05 to 101.42, p = 0.045). In conclusion, alcohol consumption and vagal activity elicit PAF significantly more often than SVT. Alcohol and vagal triggers often were found in the same patients with PAF, raising the possibility that alcohol may precipitate AF by vagal mechanisms.

Balloon Isolation of the PV

• Cryo, Laser, RF, US Energy • Potential advantages

– Applying a single lesion – Easier – Reduced procedure time – Improved Safety – Improved Success

• Disadvantages – One size does not

necessarily fit all – Does not address the PV

antrum or non-PV triggers – Phrenic Nerve Injury

Tanaka, JACC 2001

? ?

?

STOP-AF

• 245 patients paroxysmal AF • Randomized 2:1 cryo vs. medication • Acute procedural success (> 3PVs)

– 98.2% (160/163)

• Freedom from AF at 1 year – 69.9% vs. 7.3% – Included 19% Redo procedures in blanking

period – 60% single procedure success rate

Packer JACC 2013

89

Meta-Analysis of Five Studies

STOP-AF

• Complications – Phrenic Nerve Palsy 11.2% (1.8% at 1 year) – PV Stenosis 3.1% (2/7 required Rx) – Both of these complications have come down

with experience – Case reports of AE fistuale

Packer JACC 2013 Andrade Heart Rhythm 2011

Procedure Duration

Methods: • 444 procedures were

conducted in nine German centers

• Retrospective study used random record collection

• Excluded patients with serious complications

1 Medtronic, Inc. data on file. 2 Reddy VY, et al. Heart Rhythm. 2008 Mar;5(3):353-60. Epub 2007 Nov 7

Presenter

Presentation Notes

Key messages to deliver: Study conducted in Germany in 9 centers with 444 patients enrolled. The study sought to compare procedure times of Arctic Front and “point-by-point” ablation procedures. The results confirmed that Arctic Front is faster than “point-by-point” catheter systems in all 3 categories: Lab occupancy (door to door time), primary physician time (skin to skin), fluoroscopy time. Reduced lab occupancy time vs. “point-by-point” ablation with 3D mapping by 33% Reduced primary physician time vs. “point-by-point” with 3D mapping by 33% Reduced fluroscopy time vs. “point-by-point” ablation with 3D mapping by 24% Other details: - In all groups, the operating teams had performed at least 50 procedures with each technology. Individual results may vary. Product used were Irrigated tip catheters guided by CARTO XP EP Navigation System, Biosense Webster, USA or EnSite NavX™, St. Jude Medical, USA. 8 Medtronic, Inc. data on file.

AF Reduces QOL

Improved QOL: RF v. AAD

RAAFT, JAMA. 2005;293:2634-2640

Hybrid; Catheter and Surgical Ablation of Recurrent AFib

Hybrid AF Ablation

Surgeons

• Direct visualization

• Create most linear ablations quickly and effectively

• Map ganglionic plexi

• Address left atrial

appendage

Electrophysiologists

• Map for focal triggers

• Ablate areas difficult to reach from epicardial approach – Tricuspid and mitral

valve isthmus

• Rigorously assess for complete block and map/ablate gaps in a linear lesions

What Do We Do Well?

DEEP AF Epicardial Lesion Set

Good Cosmetic Result

No Rib Spreading

Ann Cardiothorac Surg 2014;3(1):38-44

N=78 Success: 100% Long-Standing Persistent 82% Persistent (85% on AAD) 76% Paroxysmal (97% on AAD) No deaths; 8% peri-procedure complication rate

Results

Patient Selection

• Long-Standing persistent Afib • Failed catheter ablation • Interest in addressing LAA • Minimally invasive approach

– No prior cardiac surgery – Weight limitations – Pectus excavatum

Right Side •Pulmonary Vein Antrum isolation

RSPV

RIPV

PV Antrum Isolation

Image courtesy of Joseph A. Pangrace © 2009

Procedure Ports Overview – Left Side

• Method of gaining access and PV isolation similar to right side

• Exclusion of LAA

Voltage map of la – pa view

Voltage Map after Roof Line

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