1、Treating Atrial FibrillationRichard Schilling,St Bartholomews Hospital, Queen Marys University of London,AF burden,Framingham Lifetime risk of developing AF = 25% Mortality: SMR =1.9 1.5 NHS audit 1% of budget spent on AF - 688, 000, 000 in 2000 Quality of life Symptoms of AF Side effects of medicat

2、ion,Benjamin, E. J. et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98.10 (1998): 946-52. Stewart, S. et al. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart 90.3 (2004): 286-92,ATRIAL FIBRILLATIONIncidence,

3、Framingham Heart Study,Nice guidance for management of AF,Issued on June 2006 Aimed to give a UK based simple guidance on management of AF Attempts to be evidence based And applicable to the majority of patients,Key aims of management,Diagnosis - everyone with irregular pulse gets ECG Identify secon

4、dary causes (thyroid, hypertension, valve disease) Treatment Stroke prevention Rate control Rhythm control where appropriate,Diagnosis,AF can only be diagnosed on an ECG recorded during symptoms/signs Even asymptomatic patients should have an ECG Consider 24 hour to 7 day Holter if intermittent (dep

5、ending on frequency) Or ask patient to attend A+E during symptoms and get a copy of ECG,Investigation,TFT Echo If young If rhythm control strategy If unsure of stroke risk If structural heart disease suspected,Stroke prevention,Warfarin (INR 2-3),Aspirin,Rate control vs rhythm control,RACE Mortality

6、 22.6% vs 17.2% 39% vs 10% in SR AFFIRM Mortality 23.8% vs 21.3 % hospitalisation Side effects SR has a prognostic benefit,Rhythm control - problem,Cardioversion and drugs maintains SR in 42% at one year (amiodarone) Side effects require stopping amiodarone in 25% Anticoagulation stopped too early,T

7、reatment decision tree,Advantages of Warfarin over Aspirin,Advantages of Warfarin over Aspirin,rhythm vs rate control,Persistent AF rate control,Specialist referral,Rhythm control,Rate control vs Rhythm control,AF is dangerous SR is better and confers mortality benefit Conventional therapies are poo

8、r at maintaining SR The population is aging,What specialist treatments are available?,Antiarrhythmic drugs Pacemaker Catheter ablation Surgical ablation,AV node ablation and pacing,AV node ablation and pacing,“hides” the AF Easy to perform (99%) success No atrial transport (turbo) Pacing dependent (

9、LBBB) No going back Refuge of the elderly and desperate,The first curative procedure MazeJL Cox et al 1991,Why does the maze work?,Radiofrequency Ablation Catheter,Lesion cross-section,How is RF energy applied,RFA Lesion - Macroscopic,Atrial fibrillation originates in the left atrium,Mechanisms for

10、AF,Target PV trigger,LIMITED BY: Absence of spontaneous ectopy Multiple triggers,Focal AF: RFA to “disconnect” PV potential,Continuous circular lesions,Catheter ablation in permanent AF,Earley et al. Heart 2005,MV,31/41(76%) in SR at 8.4 mths,The electroanatomical approach,The anatomy is very stylis

11、ed Accurate lesion location is very dependent on experience,CT integration,True 3-dimensional anatomy with catheter localisation,Creating 3 landmark pairs,LPV locations of interest,LPV internal view,Does this have a clinical effect?,LUPV,LAA,LLPV,Ablation lines,Isolation of LPVs during AF,Practicali

12、ties of curative AF ablation,Pre op - CT few weeks pre-op TOE on day ACT 300 during procedure Procedure time 2-3 hours PAF/ 3-4 hours Persistent Post-op echo Warfarin loading on night of procedure Continues for 3 months if low risk Enoxaparin day after until INR2,Case Control Study of 3-D mapping vs

13、 CT integration,105 patients 6 month follow up 7 day holter at 3 months Similar operator profile and experience,AF ablation results,Freedom from AT/AF off medication at 6 month follow up,CT integration (n = 53),3D mapping (n = 52),P value,Complications of AF ablation,2% pericardial effusion/tamponad

14、e 3% Femoral haematoma 0.5% stroke/TIA 0.5% PV stenosis,Recurrence,Usually occurs 3months (late recurrence is rare) May settle over a 3 to 6 month period Results in 28% to 40% of patients requiring redo,How does ablation compare to drugs?,Ablation vs drugs,Does ablation improve prognosis?,Pappone et

15、 al circulation 2001,Complications of AF ablation,AF ablation is good for your garden,AF ablation for heart failure,Patients with EF45% and AF Randomised to medical therapy or med therapy and catheter ablation 21 patients enrolled so far 15 patients with at least 1 month FU 7 Catheter Ablation 8 Med

16、ical,Preliminary results,2 pts recurrence after ablation awaiting redo 6pts improved 1 NYHA 5% EF after 1 month,Who should have AF ablation,Symptomatic (incl heart failure?) Persistent AF for 5 years Prepared to go through multiple procedures Prepared for the risks,Limitations of AF ablation,High volume does make a difference Redos are common Tarrif does not reflect cost Serious