PREVENTION OF ATRIAL FIBRILLATION PROGRESSION BY CATHETER ABLATION. Prof. Fiorenzo Gaita

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1 PREVENTION OF ATRIAL FIBRILLATION PROGRESSION BY CATHETER ABLATION Turin, 13 th October 2016 Prof. Fiorenzo Gaita Cardiovascular Department Director, University of Turin, Italy

2 Atrial Fibrillation Begets Atrial Fibrillation Prof. Giorgio Gamna 1976 Maurits Allessie, 1995

3 Atrial Fibrillation begets Atrial Fibrillation Effect of rapid atrial pacing on the duration of AF in goats Wijffels Circulation 1995

4 AF progression Different patterns Atrial fibrillation recurrences under treatment Progression from short to long episodes Progression from rare to frequent episodes Progression from paroxysmal to permanent

5 AF progression Different patterns Atrial fibrillation recurrences under treatment Progression from short to long episodes Progression from rare to frequent episodes Progression from paroxysmal to permanent

6 Can rhythm control strategy (both pharmacological and non-pharmacological) prevent AF progression?

7 Factors involved in AF progression Underlying disease Atrial fibrillation duration Type of treatment: pharmacological ablation protocol Physician s and patient s belief

8 Physician s and patient s belief AF progression strongly relates to the doctor s belief and then the therapeutic efforts invested Rate control Easy way Rhythm control More challenging Beta blockers Calcium channel blockers Digoxin Antiarrhythmic drugs Hospitalizations for Electrical cardioversion Transcatheter ablation

9 Progression of atrial fibrillation according to physician s choice of rhythm-control vs rate-control therapy Rhythm control 11% 2,137 pts with recently diagnosed Physician s choice of rate control paroxysmal increases AF relative risk 1,542 pts of AF progression 595 pts by 136% Progression to Permanent AF within 1 year Rate control 26% RECORD-AF survey De Vos Am Heart J 2012

10 ROCKET AF Trial patients enrollment pts Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation 5407 pts 2681 pts 2096 pts 2202 pts 1878 pts While the choice of anticoagulant was randomized, the choice of rhythm versus rate control was driven by physician s belief

11 Physician s choice of rhythm control Out of ROCKET-AF pts Persistent AF (80%) Paroxysmal AF 2802 (20%) Rhythm control 1,3% (154 pts cardioversion/ablation) Rhythm control 6,3% (176 pts cardioversion/ablation) Piccini JP; J Am Coll Cardiol 2013

12 Factors involved in AF progression Underlying disease Atrial fibrillation duration Type of treatment: ablation protocols Physician s and patient s belief

13 Atrial Fibrillation syndrome? CMP idiopathic valvular vagal thyroid SSS adrenergic pericarditis Comorbidity Valvular HCMP

14 In pts treated with antiarrhythmic drugs, AF progression relates to comorbidities 44,4 8,9 The presence of comorbidities directly increases the rate of AF progression H, hypertension (1); A, age>75 (2); T, stroke or transient ischaemic attack (1); C, chronic obstructive pulmonary disease (2*); H, heart failure (1) RECORD-AF, De Vos, Am Heart J 2012 HATCH score

15 Normal vs. Dilated left atrium

16 International Journal of Cardiology 167 (2013) studies, 7217 patients, 60% paroxysmal AF Odds Ratio Left atrium diameter and Valvular AF are the two stronger predictors of AF progression

17 Factors involved in AF progression Underlying disease Atrial Fibrillation duration Type of treatment: ablation protocols Physician s and patient s belief

18 Electrical, contractile and structural remodelling during Atrial Fibrillation Electrical Contractile Structural AERP shortening and lack of adaptation, reduced velocity in intraatrial conduction REVERSIBLE BUT TIME DEPENDENT Increased fibrosis and collagen NOT REVERSIBLE REVERSIBLE Adapted from Allessie M et al. Cardiovasc Res 2002

19 Robert S. Oakes et al, Circulation AF pts scheduled for AF ablation underwent 3D DE-MRI Paroxysmal AF Persistent AF Mild fibrosis Extensive fibrosis

20 CIRCULATION Arrhythmia Electrophysiol. 2008;1: Paroxysmal AF Persistent/long standing AF 85% 85% PVI + linear lesions 77% 75% Structural 71% remodelling PVI + linear lesions 62% impacts on PVI 46% 39% long-term progression (recurrences) Redo procedure 54% following transcatheter ablation PVI

21 AF duration relates to post ablation AF progression AF duration > 6 months risk of recurrences 42-64%

22 Factors involved in AF progression Underlying disease Atrial fibrillation duration Type of treatment: ablation protocols Physician s and patient s belief

23 Cornerstone of AF ablation NEJM 1998;339: pts with idiopathic PAF Follow-up: 8±6 months 62% success rate w/oaad

24 Is pulmonary vein isolation alone enough to treat also patients with atrial remodelling related to persistent and long-standing AF?

25 Without drugs 2005;111: Permanent AF and Valvular Heart Disease Pts in SR without drugs For Long Standing Atrial Fibrillation PV isolation alone is not sufficient: we have to add substrate modification with linear lesions or fragmented potentials U 7 PV PV

26 121 pts with refractory AF (57 PAF, 64 chronic). F-U: 1 y 84% success rate w/out AAD (16% redo)

27 Different patterns of AF progression Atrial fibrillation relapses Progression from short to long episodes Progression from rare to frequent episodes Progression from paroxysmal to permanent

28 889 patients referred for AF ablation bewteen Minimum Follow up 5 years Heart Rhythm 2014; 11(5):

29 AF ablation protocol PAROXYSMAL PV Isolation PERSISTENT and LONG-STANDING PVI + CFAE + Linear Lesions

30 Influence of AF duration on progression from paroxysmal to permanent AF 889 patients referred for AF ablation 474 (53.3%) paroxysmal AF 360 (40.5%) persistent AF 55 (6.2%) long standing persistent AF Progression to perm AF 5 years 2.7% 10% 14.5% Heart Rhythm 2014; 11(5):

31 Influence of AF duration on progression from paroxysmal to permanent AF 889 patients referred for AF ablation RECORD AF Survey rhythm control strategy with antiarrhythmic drug treatment 474 (53.3%) paroxysmal AF 1542 paroxysmal AF pts Permanent AF 5 years 2.7% 11% Permanent AF at 1 year Heart Rhythm 2014; 11(5): De Vos et al; Am Heart J 2012

32 Influence of AF duration on progression in pts w/o structural heart disease 766 patients 426 (55.6%) paroxysmal AF 298 (38.9%) persistent AF 42 (5.5%) long standing persistent AF Progression to perm AF 5 years 1.6% 6.7% 11.9% Heart Rhythm 2014; 11(5):

33 Influence of AF duration on progression in pts with structural heart disease 123 patients (44 HCM. 79 valv) 48 (39.0%) paroxysmal AF 62 (50.4%) persistent AF 13 (10.6%) long standing persistent AF Progression to perm AF 5 years 12.5% 25.8% 23.1% Heart Rhythm 2014; 11(5):

34 Conclusions AF ablation can reduce AF progression Results are impressive in patients without structural heart disease In case of structural heart disease, AF progression may be prevented in up to 75% of the cases In both cases transcatheter ablation should be performed before structural remodelling related to AF duration occur

35 Thanks for your attention

Atrial Fibrillation: Drugs, Ablation, or Benign Neglect. Robert Kennedy, MD October 10, 2015

Atrial Fibrillation: Drugs, Ablation, or Benign Neglect Robert Kennedy, MD October 10, 2015 Definitions 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary.