Atrial Fibrillation and Cardiac Device Therapy RAKESH LATCHAMSETTY, MD DIVISION OF ELECTROPHYSIOLOGY UNIVERSITY OF MICHIGAN HOSPITAL ANN ARBOR, MI

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1 Atrial Fibrillation and Cardiac Device Therapy RAKESH LATCHAMSETTY, MD DIVISION OF ELECTROPHYSIOLOGY UNIVERSITY OF MICHIGAN HOSPITAL ANN ARBOR, MI

2 Outline Atrial Fibrillation What is it? What are the associated risks? What are the treatment options? Cardiac Devices What are the different types of devices? Who should get a device? What are the long term implications of having a device?

3 Outline Atrial Fibrillation What is it? What are the associated risks? What are the treatment options? Cardiac Devices What are the different types of devices? Who should get a device? What are the long term implications of having a device?

4 Atrial Fibrillation Irregular and often rapid heart rhythm originating from the top chambers of the heart (Atria). Sinus Node Atrioventricular (AV) Node Sinus Rhythm

5 Atrial Fibrillation Irregular and often rapid heart rhythm originating from the top chambers of the heart (Atria). Atrial Fibrillation

6 Atrial Fibrillation Irregular and often rapid heart rhythm originating from the top chambers of the heart (Atria). Sinus Rhythm

7 Atrial Fibrillation Irregular and often rapid heart rhythm originating from the top chambers of the heart (Atria). Atrial Fibrillation

8 Afib Prevalence About 20% in patients with HCM 1 About 10% in patients with DCM 2 Higher prevalence may be due to: Diastolic dysfunction 3 Fibrosis Changes in autonomic system Increased stretch on atrial chambers 1 Guttmann OP, et al. Heart Mar;100(6): Aleksova A, et al. Clin Med Res Dec;8(3-4): Frontera, et al. Clin Res Cardiol Oct;104(10):

9 Afib Terminology Paroxysmal Afib Intermittent episodes terminating within 7 days Persistent Afib Afib lasting > 7 days Long-standing Persistent Afib Afib lasting > 1 year Permanent Afib Persistent Afib where decision is made to leave patient in Afib without attempts at rhythm control

10 Afib and Stroke Risk Mechanism likely multifactorial LA mechanical dysfunction/ stasis Hypercoagulable state Sohara H. JACC. 1997;29: Chen-Scarabelli C, et al. JACC. 2015:65(3):

11 Afib and Stroke Risk Patients with HCM and AF: Average annual stroke risk 3.75% Greater with other risk factors Increasing age Hypertension Previous stroke Diabetes Heart failure High LVOT gradient Patients with DCM and AF Annual stroke risk greater than general population with AF Greater with other risk factors (similar to above) Frontera A, et al. Clin Res Cardiol Oct;104(10): Guttmann OP, et al. Heart Mar;100(6):

12 Afib and Stroke Risk All patients with HCM or DCM and Afib should receive anticoagulation unless contraindicated Vitamin K antagonist (Warfarin) Newer target specific oral anticoagulants (TSOACs)

13 Although Atrial Fibrillation is very common, its mechanisms and clinical presentation are quite variable. Treatment is tailored to each patient and response to therapy can vary significantly.

14 Broad Symptom Range Debilitating symptoms Palpitations Lightheadedness Dizziness Shortness of breath Fatigue Etc. Asymptomatic

15 Variable Heart Rates Rapid Slow

16 Variable Triggers Potential Triggers Can Occur at Random

17 Variable Levels of Treatment Healthy Lifestyle Intensive Medical Therapy

18 Afib Treatment Goals Reduce Stroke Risk Alleviate Symptoms Preserve Cardiac Function

19 Afib Treatment Strategies Rhythm Control (maintain sinus rhythm) Antiarrhythmic Medications Often limited choices with HCM and DCM due to pro-arrhythmic effects Catheter Ablation Surgical MAZE Rate Control (allow patient to be in Afib) Rate control medications AV nodal ablation and pacemaker May be mildly less efficacious in patients with HCM

20 Atrial Fibrillation Key Points Most common arrhythmia Variable presentations and treatments Managing stroke risk is critical Long term management plan Rate or rhythm control Treatment plan may change over time Most patients can continue to lead very active lives

21 Future Directions Better understanding of Afib mechanisms Improved ablation technology/strategy to eliminate Afib Improved stroke risk management More effective medications Appendage occlusion devices Improved symptom monitoring and management

22 Outline Atrial Fibrillation What is it? What are the associated risks? What are the treatment options? Cardiac Devices What are the different types of devices? Who should get a device? What are the long term implications of having a device?

23 Outline Atrial Fibrillation What is it? What are the associated risks? What are the treatment options? Cardiac Devices What are the different types of devices? Who should get a device? What are the long term implications of having a device?

24 Cardiac Devices Pacemaker Implantable Cardioverter Defibrillator (ICD) Treat slow heart rates Protect against sudden cardiac death (SCD) Most also have some pacing capabilities

25 How big is a cardiac device? iphone Previous ICD Current ICD Current Pacemaker

26 Which Patients Need Pacemakers? Bradycardia (slow heart rate) due to: Sinus node dysfunction (signal generation) AV node dysfunction (signal conduction) Bradycardia causing: Symptoms Unreliable heart rate Limitations to medical therapy Sinus Node Atrioventricular (AV) Node

27 Dual Chamber Pacemaker

28 Which Patients Need an ICD? Primary Prevention Patients at risk for developing ventricular tachyarrhythmias or SCD Should be risk stratified to decide whether ICD should be implanted Secondary Prevention Patients with a history of ventricular tachyarrhythmias or aborted SCD Should receive an ICD

29 HCM Risk stratification for SCD Aborted SCD (secondary prevention) ~11% annual risk ICD Primary prevention risk factors: Massive hypertrophy (>30mm) Unexplained syncope > 1 risk factor ~2-6% annual risk Family h/o of SCD Nonsustained ventricular tachycardia ICD

30 Other (potential) Risk Factors for SCD Advanced remodeling EF < 55% Extensive scar on cardiac MRI Apical aneurysm X Complex genetics X

31 HCM SCD Risk Score: Weighting the Risk Factors Retrospective cohort of 3675 HCM patients Model includes 7 pre-specified predictors: Age Max wall thickness LVOT gradient (rest or provoked) LA size Unexplained syncope NSVT FHx SCD Risk factors are weighted in the 5 year risk calculator (last 3 are most influential) O Mahony C, et al., Eur Heart J Aug 7;35(30): Elliott PM, et al. Eur Heart J Oct 14;35(39):

32 Online SCD Risk Calculator

33 Various ICD Models

34 Single Chamber Transvenous ICD

35 Transvenous vs. Subcutaneous ICD Decades of data Pacing capabilities ATP therapy before shock Longer battery life Shorter time to therapy Outside vessels/heart Low risk of systemic infection Easier to extract

36 Subcutaneous ICD

37 ICD or Pacemaker Implantation Typically 1-3 hours One small incision upper chest Low complication rates, include: Bleeding Infection Lead dislodgement Pneumothorax Discharge next morning

38 Long Term Risks/Complications Include: Lead fracture/malfunction Pocket or lead infection Pocket erosion Inappropriate ICD shocks Electromagnetic interference

39 Long Term Management After Implant Routine clinic visit every 6 months Periodic battery (generator) changes Battery life can range from roughly 3-12 years depending on various factors Other follow up as clinically indicated Patient activity level rarely hindered by devices

40 Future Directions Smaller è Smaller è Smaller Longer battery life Improved lead technology Leadless technology More efficient shock delivery Improved patient selection criteria

41 THANK YOU!

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