Disclosures

• None

©2011 MFMER

©2011 MFMER

Interventions in Atrial Fibrillation

14th Internal Medicine Conference

Fred Kusumoto MD Professor of Medicine

Mayo Clinic March 24, 2017

Kusumoto.Fred@mayo.edu

©2011 MFMER

©2012 MFMER | slide-4

Case: 55 year old man

• Comes for a 2nd opinion

• PAF for 6 years, permanent AF 1 year

• Can still bicycle and feels “normal”

• Pacemaker 5 years ago

• Meds: dabigatran, diltiazem, losartan

• Chest pain 10 d prior – heart cath

• No significant CAD

• Severe MR

• Mild to moderate LV dysfunction

• TEE done, surgery recommended

©2012 MFMER | slide-5

Exam

• BP 116/72, pulse 72, irregular

• Grade II apical holosytolic murmur

©2012 MFMER | slide-6

©2012 MFMER | slide-7

Atrial Fibrillation

• Stroke Risk

• Symptom Management

©2011 MFMER

“Atrial fibrillation is the low back pain of cardiology”

Mike Crawford

Atrial Fibrillation

• Stroke Risk

• Symptom Management

©2011 MFMER

Relative contributions of different risk factors to the CHADS2 score (“NIH”)

10

• 73,558 patients with AF not treated with OAC (Denmark)

Olesen et al BMJ 2011;342:d124

Blackshear, Odell J Ann Thorac Surg 1996

Asirvatham 2015

Left Atrial Appendage and Stroke

• In a review of 23 studies that evaluated the presence and location of LA thrombus by TEE, autopsy or operation in the presence of AF:

• LA thrombus in 13% of RHD and 17% of nonRHD patients

• 57% of thrombi in the LAA in RHD vs. 91% in nonRHD

Courtesy Joe Blackshear

Left Atrial Appendage and Stroke

©2011 MFMER

©2011 MFMER

©2011 MFMER

“Comparison” of NOACs and LAA occlusion: Risk of stroke (and embolic events)

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1.5

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3

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Dabigatran Rivaroxaban Apixaban PROTECTAF PREVAIL

©2011 MFMER

An

nu

al R

isk (

%)

Connolly et al NEJM 2009, Patel et al 2011, Granger et al NEJM 2011, Holmes et al Lancet 2009,

Holmes et al JACC 2014

2.1 3.5 2.0 2.1 2.6 CHADS2

Warfarin

Rx

Watchman

Comparison of NOACs and LAA occlusion: Risk of bleeding

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Dabigatran Rivaroxaban Apixaban PROTECTAF

©2011 MFMER

Connolly et al NEJM 2009, Patel et al 2011, Granger et al NEJM 2011, Holmes et al Lancet 2009

Warfarin

Rx

An

nu

al R

isk (

%)

Watchman

Atrial Fibrillation

• Stroke Risk

• CHA2DS2-Vasc

• LAA occlusion in selected patients

• Symptom Management

©2011 MFMER

Atrial Fibrillation

• Stroke Risk

• CHA2DS2-Vasc

• LAA occlusion in selected patients

• Symptom Management

©2011 MFMER

MENU

“Poisons with desirable side-effects”

“Poisons with desirable side-effects.”

©2011 MFMER

Efficacy

Side-effects

Dronedarone

Flecainide

Propafenone

Sotalol

Dofetilide

Amiodarone

Goldberg et al JICE 1999

Nothing like a low bar?

Drugs that do not work too well and have side-effects/risk

*

* *

*

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

Endoscopic view of the pulmonary veins

©2011 MFMER

Endoscopic Images of the Pulmonary Veins

©2011 MFMER

LSPV LIPV

Case: Internal Cardioversion

©2012 MFMER | slide-43

©2012 MFMER | slide-44

Decreased mitral regurgitation: AF ablation

Interventional Options in Atrial Fibrillation

• Stroke Risk

• LAA occlusion in selected patients?

• Symptom Management

• Catheter ablation in selected patients? (Drug refractory, symptomatic, PAF?)

• Catheter ablation does not affect stroke risk

©2011 MFMER

©2011 MFMER