Catheter Ablation as a First LineTreatment of AFib

Transcription

1 Catheter Ablation as a First LineTreatment of AFib Jim Stone MD FACC Spring 2015

2 Catheter Ablation Uses a series of long, thin wires (catheters) that are inserted through an artery or a vein and then guided through to the heart. One of the catheters is then used to localise the source of the abnormal electrical signals and another then delivers high energy waves that neutralise (ablate) abnormal areas. Using catheters to reach the heart is a common approach to treat a range of heart conditions and is much less invasive than surgical treatments.

3 Landmarks in Catheter Ablation Techniques Maze reproduction Schwarz 1994 Right atrial linear lesions Haïssaguerre 1994 Right and left atrial linear lesions Haïssaguerre 1996 PV foci ablation Technique Jaïs / Haïssaguerre 1997/8 Ostial PV isolation Haïssaguerre 2000 Circumferential PV ablation Pappone 2000 Ablation of non-pv foci Lin 2003 Antral PV ablation Maroucche / Natale 2004 Double Lasso technique Ouyang / Kuck 2004 CFAE sites ablation Nademanee 2004 Ostial or circumferential or antral PV ablation plus extra lines (mitral isthmus, posterior wall, roof) Circumferential PV ablation with vagal denervation Publication date Jaïs / Hocini 2004/5 Pappone 2004

4 1998: Ablation of PV Foci Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins Haïssaguerre, M, Jaïs, P, Shah, DC, et al. N Engl J Med (1998) 339: 659 Pivotal study identifying the pulmonary veins as a major source of ectopic electrical activity Radiofrequency ablation of ectopic foci was associated with a 62% success rate (absence of recurrence at 8 6m follow-up)

5 A Combination of Techniques may now be used Depending on the Type of AFib AFib Trigger - Ectopic Foci Autonomic Nervous System Substrate - Atrial tissue PV & non-pv Foci Ablation, PV Isolation Vagal Denervation (parasympathetic ganglia ablation) CFAEs Ablation Linear Lesions (e.g. mitral isthmus, roof)

6 PV Antrum Isolation Guided by CARTOMERGE Image Integration Software Module LUPV LA RUPV RMPV LLPV AC RLPV Courtesy of Professor Antonio Raviele, Mestre, Italy

7 Catheter Visualization under Fluoroscopic Guidance Ablation catheter LASSO LAO RAO

8 Efficacy and Safety of Catheter Ablation

9 Meta-analysis of Catheter Ablation Ablation method Patients Paroxysmal AF SHD 6-month cure 6-months OK Linear % 26% 33% 55% Focal % 35% 54% 71% Isolation 2,187 83% 36% 62% 75% Circumferential (all) Circumferential (LACA, WACA) Circumferential (PVAI) Substrate ablation (CFAE) 15,455 68% 37% 64% 74% 2,449 65% 37% 59% 72% 11,132 68% 42% 67% 76% % 49% 75% 87% TOTAL 23,626 61% 55% 63% 75% Cure (by each author s criteria) means no further AFib 6 months after the procedure in the absence of AAD. OK means improvement (fewer episodes, no episodes with previously ineffective AAD). SHD indicates structural heart disease. Fisher JD, et al. PACE (2006) 29: 523

10 Worldwide Survey on Efficacy and Safety of Catheter Ablation for AFib Total success rate: 76% Of 8745 patients: 27.3% required 1 procedure 52.0% asymptomatic without drugs 23.9% asymptomatic with an AAD within <1 yr Outcome may vary between centres Cappato R, et al. Circulation (2005) 111: 1100

11 Survival probability (%) Improved Survival with Ablation vs Drug Treatment 589 ablated patients compared with 582 on AADs Ablation Group Medical Group Expected Observed One-sample log-rank test Obs=36, Exp=31, Z=0.597, p= Days of follow-up One-sample log-rank test Obs=79, Exp=341, Z=7.07, p< Days of follow-up 1080 Pappone C, et al. J Am Coll Cardiol (2003) 42: 185

12 AFib-free survival probability (%) More AFib-free Patients with Catheter Ablation vs Drug Treatment Ablation Group Medical Group No. at risk Ablation Medical Follow-up (days) Pappone C, et al. J Am Coll Cardiol (2003) 42: 185

13 Randomised Clinical Trials of Catheter Ablation RF ablation vs AAD as first-line treatment for AFib Wazni OM et al. JAMA (2005) 293: Catheter ablation in drug-refractory AFib Stabile G et al. Eur Heart J (2006) 27: Circumferential PV ablation for chronic AFib Oral H et al. N Engl J Med (2006) 354:

14 AFib.free survival RF Ablation vs Antiarrhythmic Drugs as First-line Therapy Patients randomised to receive ablation (n=33) or AADs (n=37): AFib-free Survival PVI Group Antiarrhythmic Drug Group Follow-up (days) Wazni OM, et al. JAMA (2005) 293: 2634

15 AFib-free survival (%) Catheter Ablation vs. AADs Alone in Drug-refractory AFib AADs plus ablation (n=68) or AADs alone (n=69): 1 year follow-up 100 Ablation Group Medical Group Months Stabile G, et al. Eur Heart J (2006) 27: 216

16 Sinus rhythm (%) Randomized Controlled Trial of Amiodarone + Cardioversion + Catheter Ablation Amiodarone & cardioversion (n=69) vs. amiodarone & cardioversion plus PV ablation (n=77) 100 Circumferential pulmonary-vein ablation Control Months Oral H, et al. N Engl J Med (2006) 354: 9

17 Freedom from Recurrent AFib Catheter Ablation is Successful in the Long Term 1.0 No ERAF ERAF Months after PV isolation Oral H, et al. J Am Coll Cardiol (2002) 40: 100

18 Complications Reported by Leading Centres Major complications with pulmonary vein ablation in 1039 patients (6 series) Complication Events (n) Rate (%) Range in studies (%) Transient ischaemic attack Permanent stroke Severe PV stenosis (>70%, symptomatic) Moderate PV stenosis (40-70%, asymptomatic) Tamponade / perforation Severe vascular access complication Verma A & Natale A Circulation (2005) 112: 1214

19 Cost Effectiveness Analyses of Catheter Ablation

20 Catheter Ablation May Be More Costeffective than Pharmacological Therapy After 5 years, the cost of RF ablation was below that of medical management and further diverged thereafter 118 patients with symptomatic, drug-refractory AFib 1.52 ± 0.71 ablation procedures 32 weeks Pharmacological treatment 1590/year Catheter ablation 4715 followed by 445/year Weerasooriya R, et al. Pacing Clin Electrophysiol (2003) 26: 292

21 Differences in Hospital Visits and Costs with and without Catheter Ablation Although the initial cost of ablation is high, after ablation, utilization of healthcare resources is significantly reduced No ablation Catheter ablation Clinical visits per year 7.4 (2.5) 1.1 (0.6) Emergency room visits per year 1.7 (0.9) 0.03 (0.17) Hospitalization days per year 1.6 (0.8) 0 (0) Healthcare costs per year $1920 (889) $87 (68) Goldberg A, et al. J Interv Card Electrophysiol (2003) 8: 59

22 Catheter Ablation Cost-Effective in Patients at High Risk of Stroke Model to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of AFib The use of LACA may be cost-effective in patients with AFib at moderate risk for stroke This model did not find it to be cost-effective in low-risk patients. Conclusions Cost-effective in patients at moderate or high risk of stroke Chan DP, et al. J Am Coll Cardiol (2006) 47: 2513

23 Recent Commentary Why Ablation for AFib might be Considered First- Line Therapy for Some Patients Current therapies, especially AAM, not only are ineffective but also pose a threat to patient QoL and even longevity. In the hands of experienced operators, AF ablation is an effective, safe, and established treatment for AF that offers an excellent chance for a lasting cure unlike other therapies, ablation tackles AF at its electrophysiological origin. Verma A & Natale A Circulation (2005) 112: 1214

24 Summary of catheter ablation (I) Catheter ablation for AFib has undergone significant methodological and technical revolution since its initial appearance two decades ago Discovery that PVs are a major source of ectopic triggers was pivotal in determining efficacy of procedure Significant technological advances in catheters and imaging are further improving the efficiency of catheter ablation 3D reconstructions of actual left atrial PV anatomy using CT, MRI, or intracardiac echography enables ever more accurate placement of lesions

25 Summary of catheter ablation High success rate Improves survival, cardiac function and freedom from recurrence New data from RCTs confirm benefits Safe, with a risk comparable to other low-risk, routine interventions Cost effective compared to standard pharmacological therapy, at least in patients at moderate thromboembolic risk

26 Current Guidelines and Summary

27 From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society J Am Coll Cardiol. 2014;64(21): doi: /j.jacc Figure Legend: Strategies for rhythm control in patients with paroxysmal and persistent AF. *Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). Drugs are listed alphabetically. Depending on patient preference when performed in experienced centers. Not recommended with severe LVH (wall thickness >1.5 cm). Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. Should be combined with AV nodal blocking agents. AF indicates atrial fibrillation; AV, atrioventricular; CAD, coronary artery disease; HF, heart failure; and LVH, left ventricular hypertrophy. Date of download: 3/18/2015 Copyright The American College of Cardiology. All rights reserved.

28 Summary Class I 1.AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythmcontrol strategy is desired ( ). (Level of Evidence: A) 2.Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C)

29 Summary cont. Class IIa 1.AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (157, ). (Level of Evidence: A) 2.In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy ( ). (Level of Evidence: B)

30 Summary cont. Class IIb 1.AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired (154,167). (Level of Evidence: B) 2.AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythmcontrol strategy is desired. (Level of Evidence: C)

31 Summary cont. Class III: Harm 1.AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and after the procedure. (Level of Evidence: C) 2.AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)