quando è inevitabile pensare all ’ablazione della ... · quando è inevitabile pensare all...
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Quando Quando èè inevitabile pensare allinevitabile pensare all ’’ablazione ablazione della fibrillazione atrialedella fibrillazione atriale
Dr. Alessandro ProclemerDr. Alessandro Proclemer
SOC Cardiologia SOC Cardiologia –– Fondazione IRCAB Fondazione IRCAB Az. OspedalieroAz. Ospedaliero --Universitaria Universitaria –– UdineUdine
Lucca 29 novembre 2013Lucca 29 novembre 2013
Kirchhof F et al. Europace 2013;15:1540–56
Proceedings from the fourth Atrial Fibrillation competence NETwork/EHRA consensus conference
Efficacy and safety of catheter ablation versus antiarrhythmic
drugs for atrial fibrillation:a meta-analysis of randomized
trials
Bonanno et al 2010 J Cardiov Med 11;6:408
Nielsen et al. N Engl J Med 2012;367:1587-95
RF Ablation as Initial Therapy in Paroxysmal AF: MANTRA-PAF Clinical Trial
Long-term Outcomes of Catheter Ablation of AF: A Systematic Review and Meta-analysis
> 3 years
Ganesan et al. J Am Heart Assoc. 2013;2:e004549
Long-term Outcomes of Catheter Ablation of AF: A Systematic Review and Meta-analysis
Ganesan et al. J Am Heart Assoc. 2013;2:e004549
PVI – Udine EP Lab experienceEnrollment Period: January 2004 – December 2012
Follow-Up : 54 ± 30 months
Total Paroxysmal Persistent Permanent
N°patients 315 258 (82%) 51 (16%) 6 (2%)
Age (years) 59 ± 10 60 ± 9 58 ± 11 58 ± 10
Male sex234
(74%) 186 (72%) 43 (83%) 5 (83%)
Left atrium AP diameter (mm) 47 + 7 46 + 8 49 + 5 * 51 + 13
Number of episodes per month
/ 18 + 22 / /
N°AA drugs 2 + 1 2 + 1 2 + 1 3 + 2
Amiodarone 200(63%) 152 (59%) 42 (82%)* 6 (100%)*P<0,05
Clinical characteristicsEnrollment Period: January 2004 – December 2012
Total Paroxysmal Persistent Permenent
CHADS-VASC=0 159 (50%) 133 (52%) 22 (43%) 3 (50%)
CHADS-VASC= 1 97 (40%) 80 (31%) 14 (27%) 3 (50%)
CHADS-VASC ≥2 59 (19%) 45 (17%) 15 (29%) 0
Heart disease (27%) (24%)* (44%)* ( 100%)
*P=0,04
Persistent Paroxysmal Total
population
Dilatative
Tachy-
cardiom.
Ipertensive
Ischemic
Ione AF
Procedural dataTotal Paroxysmal Persistent Permanent
Overall procedural time (min) 158± 30 156± 31 165± 26 150± 20
Fluoroscopy time (min) 49± 16 48± 16 53± 16 49± 11
RF time (min) 31 ± 10 31 ± 10 32 ± 9 26± 12
Multiple Procedures 45 (14%) 36 (14%) 9 (18%) 0
Previous Flutter ablation 44(14%) 37 (14%) 5 (10%) 2 (33%)
Concomitant Flutter ablation 84(27%) 75 (29%) 8 (16%) 1(17%)
Recidiva post ablazioneP=NS
0 12 24 36 48 60 72 84
100
90
80
70
60
50
40
mesi
% li
bera
da
FA
Number at riskGroup: <3
104 77 58 44 30 18 12 3Group: =>3
147 99 79 57 40 24 7 2
Risk of recurrence according to years from first diagnosis
< 3 years
≥3 years
64%
45%
(P<0,0001)
0 12 24 36 48 60 72 84
100
90
80
70
60
50
40
30
20
mesi
% li
bera
da
reci
diva
di F
A
Number at riskGroup: normale
105 83 63 50 34 22 8 2Group: obeso
49 23 21 12 9 6 2 1Group: sovrappeso
97 70 53 39 27 14 9 2
BMI < 25
BMI ≥ 30
BMI 25-29
Risk of recurrence according to BMI
66%
53%
30%
recidiva post ablazione in funzione delle dimensioni eco dell'atrio sinistroP < 0,0001
0 12 24 36 48 60 72 84
100
80
60
40
20
0
mesi
% li
bera
da
FA
Number at riskGroup: 1
113 84 61 39 18 16 3 0Group: 2
58 46 37 35 27 16 10 5Group: 3
80 46 39 27 25 10 6 0
≤ 40mm≤
40-50mm
≥50mm
Risk of recurrence according to LA diameter
63%
57%
32%
Carto-Merge (CT+EA Map)
Male, 45 yrs, paroxysmal idiop. AF Female, 33 yrs, persistent AF, BMI >30 kg/m 2
Left Atrial Sphericity: A New Method to Assess Atrial Remodeling. Impact on the Outcome of AF Ablation
Bisbal F et al J Cardiovasc Electrophysiol 2013:24 ;752-9
Predicted AF recurrence after ablation
By Left Atrial Sphericity and hypertension (HT)Predicted AF recurrence after ablation
By LA Sphericity and hypertension (HT)
MRI of the left atrium: predicting clinical outcomes after atrial fibrillation ablation
Daccarrett M et al. Expert Rev Cardiovasc Ther. 201 1; 9(1): 105–111.
AF Ablation: outcomes in 2013
Single Procedure Multiple Procedure
Optimal Candidate: 60 – 80% 70 – 90%
Moderate Candidate: 45 – 65% 55 – 75%
Poor Candidate: 35 – 50% 45 – 60%
Success is defined as freedom from symptomatic AF at 12 months of follow-up.
Patient Selection for Ablation
Courtesy of Hugh Calkins, MD.
More Optimal Patient Less Optimal Patient
Variable
Symptoms Highly symptomatic Minimally symptomatic
Class I and III drugs failed ≥≥≥≥1 0
AF type Paroxysmal Long-standing persistant
Age Younger (<70 years) Older ( ≥≥≥≥70 years)
LA size Smaller (<5.0 cm) Larger ( ≥≥≥≥5.0 cm)
Ejection fraction Normal Reduced
Congestive heart failure No Yes
Other cardiac disease No Yes
Pulmonary disease No Yes
Sleep apnea No Yes
Obesity No Yes
Prior stroke/TIA No Yes
Conclusions
• The long-term freedom of atrial arrhythmia can be achieved after AF ablation in the majority of cases, taking into account the need for multiple procedures
• Success rates are dependent on the intensity of
monitoring, the definition of success, the AF
type and several clinical and laboratory
parameters
• A personalized atrial fibrillation management
should be considered even before AF ablation
Weerasooriya et al. J Am Coll Cardiol 2011;57:160–6
Single ablation attempt
Last ablation attempt
Catheter Ablation for AF in 100 pts: 5 yrs FU
0 100 200 300 400 500
Days
0%
20%
40%
60%
80%
100%
Tre
atm
ent S
ucce
ss
Primary Effectiveness Analysis Treatment Success
BlankedforDetectableAF
vs 7.3% (SE 2.9%)vs 7.3% (SE 2.9%)
CRYO 69.9% 114 / 163 CRYO 69.9% 114 / 163
DRUG 7.3% 6 / 82DRUG 7.3% 6 / 82
30 days
KM estimate 68.6% (SE 3.9%)KM estimate 68.6% (SE 3.9%)
OR = 29.5 (12.0 – 72.2) p < 0.001
• Safety and efficacy of the catheter ablation in:
- very elderly
- heart failure
- long standing persistent AF
• Impact of AF ablation on stroke risk.
• Impact of AF ablation on survival.
• Technical questions.
- optimal ablation strategy for long standing persis tent
AF
- relative efficacy of cryo ablation, RF ablation, a nd laser
ablation
Where Are the Knowledge Gaps?
Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial
Narayan et al. J Am Coll Cardiol 2012;60:628-36
Narayan et al. J Am Coll Cardiol 2012;60:628-36
Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial
Narayan et al. J Am Coll Cardiol 2012;60:628-36
Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial
Narayan et al. J Am Coll Cardiol 2012;60:628-36
Treatment of AF: Ablation of Localized SourcesCONFIRM (Conventional Abl. for AF W/Wo Focal Impuls e and Rotor Modulation) Trial
Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU
Ouyang et al. Circulation. 2010;122:2368-2377
Ouyang et al. Circulation. 2010;122:2368-2377
Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU
Ouyang et al. Circulation. 2010;122:2368-2377
Long-Term Results of Catheter Ablation in Paroxysmal AF Lessons From a 5-Year FU
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Time to recurrence of AF influences outcome following catheter ablation
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Time to recurrence of AF influences outcome following catheter ablation
Time to recurrence of AF influences outcome following catheter ablation
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Time to recurrence of AF influences outcome following catheter ablation
Piccini et al. Circulation. 2012;126:2200-2207
Outcomes of Medicare Beneficiaries Undergoing Catheter Ablation for AF: 15423 pts, 2007-2009
P HR 95% CI
Age 0,7463 1,00 0,9793 - 1,0297
Sex (F) 0,7105 1,12 0,6195 - 2,0219
BMI ≥ 30 <0.0001 4,6 2,5782 - 8,3563
BMI : 25-29 0,004101 2,3 1,3005 - 3,9601
Years from first
diagnosis0,1593 1,04 0,9857 - 1,0935
CHADS-Vasc 0,6324 0,88 0,5237 - 1,4801
Structural heart
disease0,6381 1,65 0,2067 - 13,1763
LA diameter <0.0001 1,1 1,0574 - 1,1048
Overall procedural time 0,3858 1,00 0,9946 - 1,0142
RF time 0,6717 1,00 0,9814 - 1,0297
Fluoroscopy time 0,7086 0,10 0,9766 - 1,0162
Persistent AFib 0,6567 1,14 0,6359 - 2,0545
Procedure without EA
mapping0,02361 1,6 1,0705 - 2,4990
Univariate/multivariate Cox proportional hazards analyses
Total number 30 (9,5%)
Major complications 20 (6,3%)
Cardiac tamponade 5 (1,6%)
Pericadial effusion 5 (1,6%)
Ictus/TIA 2 (0,6%)
Cerebral hemorrhage 1 (<0,5%)
PV stenosis 1 (<0,5%)
Local hematoma 10 (3,2%)
Retroperitoneal hematoma 1 (<0,5%)
Arteriovenous fistula 4 (1,3%)
Phrenic nerve injury 1 (<0,5%)
Complications
Symptomatic and Asymptomatic Episodes of AF Before and After Catheter Ablation (DISCERN AF)
Verma et al. JAMA Intern Med. 2013;173(2):149-156
Verma et al. JAMA Intern Med. 2013;173(2):149-156
Symptomatic and Asymptomatic Episodes of AF Before and After Catheter Ablation (DISCERN AF)
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Time to recurrence of AF influences outcome following catheter ablation
Gaztanaga et al. Heart Rhythm 2013;10:2–9
Time to recurrence of AF influences outcome following catheter ablation
CRT with mild HF: a systematic review and meta-analysis
Santangeli et al. J Interv Card Electrophysiol 2011;32:125-35