10/10/19 Disclosure Ablation and Devices for Atrial Fibrillation – SentreHeart/Atricure, Inc Should all Patients have Ablation? 1 2 AF PAROXYSMAL PERSISTENT AF LONG STANDING AF . PERMANENT AF . Diagnosis AF Risk Factor Modification 33.5 Million WW 3 • HTN High BP • DM CHD Rheumatic HD 4 • Obesity Hyperthyroidism 2 Obesity/Diabetes Behaviors Increase • Sleep Apnea Sleep Apnea Risk HX of AF Alcohol and Caffeine • Alcohol High Stress 1 • Excercise INTRODUCTION GROWTH MATURITY DECLINE 3 4 1
10/10/19 Obesity and AF Progression Obesity (BMI ≥30 kg/m 2 ) 2010 1994 2000 No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% Hypertension Diabetes Sleep Apnea Curtesy of Suneet Mittal Tsang et al. EHJ 2008 5 6 Standard “Historical” Treatment for AF A cardiac disease that kills by producing emboli Restore Maintain Protect 7 8 2
10/10/19 Anti-arrhythmic Drugs The Real Debate • Amiodarone • Anti-arrhythmic drugs versus catheter ablation – Toxicities: Lung, Thyroid, Cataracts, Skin, Neurological • Class Ic (encainide, flecainide, propafenone) – Increase mortality in patients with ischemic heart disease • Dofetilide/Sotalol – Torsade Echt DS et al. N Engl J Med 1991;324:781-788. 9 10 Potential Sites of Triggers * ** ** ** ** 11 12 3
10/10/19 Cornerstone of AF Ablation is PVI Additive Catheter Ablation Strategies Brooks AG, et al. Outcomes of long standing persistent AF: A systematic review. Heart Rhythm . 2010; 7:835-46 13 14 Benefit of LAA Closure “Gold Standard” for Non- Pharmacological Treatment of AF “Cut and sew” AF, Hx TE, No OAC Cox Maze III Cut and sew Maze Cox-Maze AF, No TE, No OAC AF, Hx TE, OAC AF, No TE, OAC AF, No Risk, No TE, No OAC Post maze, No OAC, No LAA Cox J., et al. J Thorac Cardiovasc Surg 1999;118:833-840 Prasad SM. J Thorac Cardiovasc Surg. 2003;126:1822-28. 15 16 4
10/10/19 UCSF Sub-X MAZE (Epicardial) C E A B B D F LAA 17 18 Case Presentation • 55 yo gentleman – Hx of longstanding AF SVC – CHADs score 1 • Multi-center, prospective randomized trial – Refractory to medical therapy T – Failed 2 previous PV • Comparing LAA ligation and PVI versus PVI in V • How do you treat this patient? MV patients with persistent and longstanding IV – Repeat PVI persistent AF C – AVJ ablation and pacemaker – Surgical MAZE – Rate control and OAC therapy; and live with your symptoms • LAA ligation, PVI, LAPWI, CTI 5/2011 (Percutaneous “MAZE”) – Remains in sinus rhythm 19 20 5
10/10/19 Land Mark Trials CABANA Trial CABANA trial Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial Crystal AF trial Relieve Symptoms Improve cardiovascular outcomes 21 22 Kaplan-Meier Estimates of the Primary End Point Cabana Trial (composite of death, disabling stroke, serious bleeding, or cardiac arrest) • Primary end point: – Composite of death, disabling stroke, serious bleeding, or cardiac arrest. • Secondary endpoints: – all-cause mortality – total mortality or cardiovascular hospitalization – and AF recurrence 23 24 6
10/10/19 Recurrent Atrial Fibrillation After Blanking by The composite secondary end Intention-to-Treat Analysis point of death from any cause or CV hospitalization 25 26 Case Case • In 2002, 61 year old man with history of asymptomatic AF • In 2017, Presents to clinic for second opinion – Treated with rate control and warfarin – Still being treated with rate control and warfarin AFIRM Trial RACE-2 Trial – Normal LVEF in 2002, now LVEF is 35% (AFFIRM) Investigators. N Engl J Med 2002;347:1825-1833. Van Gelder IC et al. N Engl J Med 2010;362:1363-1373. 27 28 7
10/10/19 The CASTLE-AF Trial Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation Primary Endpoint Inclusion Criteria • All-cause mortality • Symptomatic PAF or Persistent AF • Worsening heart failure admissions • Failure or intolerance to AAD or unwillingness to take AAD • LVEF < 35% • NYHA class > II 29 30 31 32 8
10/10/19 Summary • Drugs – Toxicities – don’t work long term – can lead to death • Catheter ablation – Decreases symptoms – Prevents CHF – Improves mortality 33 34 9
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