We should not ablate atrial fibrillation in young asymptomatic patients Joshua D. Moss, MD, FACC, FHRS Associate Professor of Clinical Medicine Cardiac Electrophysiology University of California San Francisco @JDMossMD 1 First: important to define “young” versus “old” (You know it when you see it) DEC 06 ‘19 DEC 06 ‘19 2 1 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
What is the purpose of rhythm control in AF? A. To save lives B. To prevent strokes C. To make EKG’s less ugly D. To prevent Apple Watch alerts E. To make patients feel better 3 What is the purpose of rhythm control? A. To save lives B. To prevent strokes C. To make EKG’s less ugly D. To prevent Apple Watch alerts E. To make patients feel better Packer DL et al. CABANA trial, JAMA 2019; 321: 1261-1274. 4 2 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
What is the purpose of rhythm control? 1 o endpoint: death, disabling stroke, serious bleeding, cardiac arrest A. To save lives B. To prevent strokes C. To make EKG’s less ugly D. To prevent Apple Watch alerts E. To make patients feel better Packer DL et al. CABANA trial, JAMA 2019; 321: 1261-1274. 5 But the ”younger” patients did better! Packer DL et al. CABANA trial, JAMA 2019; 321: 1261-1274. 6 3 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Duh! Vs. drugs!! And had to have a comorbidity! Packer DL et al. CABANA trial, JAMA 2019; 321: 1261-1274. 7 What is the purpose of “per-protocol” analysis? 1 o endpoint: death, disabling stroke, serious bleeding, cardiac arrest (actually ablated by 12 mos after randomization) Packer D et al. CABANA trial, presented at HRS 2018. https://www.cabanatrial.org 8 4 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Adverse events in CABANA Ablation Drugs Solution: no amio!! Good thing in a clinical trial… 9 But there was 1 of these… 10 5 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
And 1 of these… 11 And 1 of these… Pre-ablation Post-ablation LIPV 12 6 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
So are there any trials of ablation in asymptomatic patients? § 66 patients with asymptomatic persistent AF refractory to AAD • “None of the usual AF-related symptoms including palpitations, SOB, chest pressure or pain, dizziness, fatigue, weakness, etc. • Mean age 52.0 +/- 9.0 § 132 matched patients with symptomatic persistent AF • Mean age 53.1 +/- 8.6 Wu L et al. J Cardiovasc Electrophysiol 2016; 27: 531-535 13 Ablation in asymptomatic patients: Asymptomatic patients § 43 of 66 in an arrhythmia at 1 year • 25.6% “pure AT” • 44.2% paroxysmal AT and AF • 30.2% persistent AF § 16 were symptomatic!! • 37.2% of those with recurrence • 24% of all originally asymptomatic patients Wu L et al. J Cardiovasc Electrophysiol 2016; 27: 531-535 14 7 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Cohen A. Watch What Happens Live with Andy Cohen. Bravo 2018. 15 Cohen A. Watch What Happens Live with Andy Cohen. Bravo 2018. 16 8 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Quality of life before and after ablation: Symptomatic patients Asymptomatic patients Wu L et al. J Cardiovasc Electrophysiol 2016; 27: 531-535 17 Desperate to try rhythm control? Well which significantly different outcome would you choose? Hakalahti A et al. Radiofrequency ablation vs. antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis. Europace 2015; 17: 370-378. 18 9 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
So what should we do for these patients? Packer DL et al. CABANA trial, JAMA 2019; 321: 1261-1274. 19 Perhaps lifestyle modification and weight loss? § Of 1415 consecutive AF patients, 825 with BMI ≥ 27 were offered weight and risk factor management § Results were stratified by degree of weight loss Middeldorp ME…Sanders P et al. REVERSE-AF . Europace 2018; 20: 1929-35 20 10 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Perhaps lifestyle modification and weight loss? § Of 1415 consecutive AF patients, 825 with BMI ≥ 27 were offered weight and risk factor management § Results were stratified by degree of weight loss Middeldorp ME…Sanders P et al. REVERSE-AF . Europace 2018; 20: 1929-35 21 Finally, what do the “experts” say? § “…the potential benefits of the procedure for the patient without symptoms are uncertain .” § “ At the end of the day , the writing group believes that in selected patients, after a careful discussion of the risks, benefits, and alternatives, that AF ablation may be considered in patients with asymptomatic paroxysmal or persistent AF (Class IIb, LOE C- EO )” Calkins H et al. Heart Rhythm 2017; 14; e275-e444. 22 11 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
What do the “experts” say? § “…the potential benefits of the procedure for the patient without symptoms are uncertain .” § “ At the end of the day , the writing group believes that in selected patients, after a careful discussion of the risks, benefits, and alternatives, that AF ablation may be considered in patients with asymptomatic paroxysmal or persistent AF (Class IIb, LOE C- EO )” 23 Conclusion: I believe in ablation! It has an important role in the treatment of atrial fibrillation. But it is not for asymptomatic young patients: 1. It offers no mortality or stroke benefit 2. It can turn an asymptomatic arrhythmia into a symptomatic one 3. There’s a good chance more than one procedure will be required, each carrying small but real risks for serious complications 4. First line in many patients should probably be risk factor modification and weight loss! 24 12 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
@JDMossMD 25 13 12/8/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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