Pulmonary Vein Isolation: Who Should Be Considered?

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1 Pulmonary Vein Isolation: Who Should e Considered? Paul A. Rogers, MD, PhD Clinical Cardiac Electrophysiology John Ochsner Heart and Vascular Institute

2 None Disclosure of Relationships

3 Atrial Fibrillation Triggers Freedom from AF in 28/38 pts. (62%) at 8±6 months Haïssaguerre M et al. N Engl J Med 1998;339:

4 % change ThermoCool AF Freedom from Symptomatic Atrial Arrhythmias 10 Improvement in Quality of Life 70% RFA N= (12.6%) redo 5 19% AAD N= RFA AAD 36 (65%) crossover SF-36 SF-36 Symptom Symptom mental physical frequency severity Wilbur D et al. JAMA. 2010;303(4):

5 Case 1 A, 79 year-old woman Symptomatic persistent atrial fibrillation x 4 months DCCV x 4 Failed sotalol, currently taking amiodarone PMHx: HTN, hypothyroidism, mild cardiomyopathy, COPD ECHO: LVEF 45%, no LVH, normal LA size

6 Case 1 A. Increase Metoprolol C. Offer PVI. PPM/AV node RFA D. DCCV

7 Patients without Atrial Tachyarrhythmias in the Absence of Antiarrhythmic-Drug Therapy. 70% 4% IIa Symptomatic persistent AF, failed prior AAD Oral H et al. N Engl J Med 2006;354:

8 Case 2 RM, 54 year-old man Symptomatic, paroxysmal atrial fibrillation x 2yrs Flecainide 100mg twice daily + metoprolol x 8 months, still with recurrences Recent admission, converted while being rate controlled with diltiazem gtt PMHx: HTN, CAD prior MI/PCI, obesity, SSS s/p PPM ECHO: LVEF 65%, no LVH

9 Case 2 A. Change to Class III AAD C. Offer PVI. AVN RFA D. Continue Flecainide

10 Freedom from recurrent AF without AAD (RFA group) after the 90-day treatment adjustment period 89% N=52 23% N=55 Mean AADs used: 2.5 ± 1 I Symptomatic paroxysmal AF, failed prior AAD Pierre Jaïs et al. Circulation. 2008;118:

11 Case 3 JL, 45 year-old man Symptomatic, paroxysmal atrial fibrillation x 5 months Episodes typically last 4-5 hours, has 1-2 episodes weekly. Diagnosed with outpatient monitoring Exercised regularly before, now afraid to due to induction of atrial fibrillation. Has read about PVI and strongly prefers to avoid medications. PMHx: none ECHO: LVEF 65%, no LVH, normal LA size

12 Case 3 A. Initiate AAD/Class 1 agent C. Monitor for progression. Restrict exercise D. Offer PVI

13 Time to First Recurrence of any Atrial Tachyarrhythmias (A) and Symptomatic Atrial Tachyarrhythmias () IIa Recurrent symptomatic paroxysmal AF, no prior AAD Morillo CA et al. JAMA. 2014;331:

14 Case 4 DS, 76 year-old man Persistent atrial fibrillation x 2 years Currently without observable symptoms Tried DCCV x 3 with anti-arrhythmic therapy Flecainide, sotalol, amiodarone PMHx: hypertension, diabetes mellitus II ECHO: LVEF 65%, severe left atrial enlargement

15 Case 4 A. AVN RFA/PPM C. Continue current management. Try Multaq/DCCV D. Offer PVI

16 2014 AHA/ACC/HRS AF Guidelines After failing Class I/III AAD No Prior Class I/III AAD January CT et al. J Am Coll Cardiol. 2014;64:

17 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF No Prior Class I/III AAD January CT et al. J Am Coll Cardiol. 2014;64:

18 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF No Prior Class I/III AAD January CT et al. J Am Coll Cardiol. 2014;64:

19 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF Symptomatic LS Pe AF No Prior Class I/III AAD January CT et al. J Am Coll Cardiol. 2014;64:

20 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF Symptomatic LS Pe AF No Prior Class I/III AAD Symptomatic Pa AF January CT et al. J Am Coll Cardiol. 2014;64:

21 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF C Symptomatic Pe AF Symptomatic LS Pe AF No Prior Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF January CT et al. J Am Coll Cardiol. 2014;64:

22 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF C C Symptomatic Pe AF Symptomatic LS Pe AF No Prior Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF Symptomatic LS Pe AF January CT et al. J Am Coll Cardiol. 2014;64:

23 2014 AHA/ACC/HRS AF Guidelines A After failing Class I/III AAD Symptomatic Pa AF C C Symptomatic Pe AF Symptomatic LS Pe AF No Prior Class I/III AAD Symptomatic Pa AF Symptomatic Pe AF Symptomatic LS Pe AF January CT et al. J Am Coll Cardiol. 2014;64: C Stand alone surgical ablation

Presenter Disclosure Information

2:15 3 pm Managing Arrhythmias in Primary Care Presenter Disclosure Information The following relationships exist related to this presentation: Raul Mitrani, MD, FACC, FHRS: Speakers Bureau for Medtronic.