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1、Treating Atrial FibrillationRichard Schilling,St Bartholomews Hospital,Queen Marys University of London,AF burden,FraminghamLifetime risk of developing AF=25%Mortality:SMR=1.9 1.5 NHS audit1%of budget spent on AF-688,000,000 in 2000Quality of life Symptoms of AFSide effects of medication,Benjamin,E.
2、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,FraminghamHeart Study,Nice guid
3、ance for management of AF,Issued on June 2006Aimed to give a UK based simple guidance on management of AFAttempts to be evidence basedAnd applicable to the majority of patients,Key aims of management,Diagnosis-everyone with irregular pulse gets ECGIdentify secondary causes(thyroid,hypertension,valve
4、 disease)Treatment Stroke preventionRate controlRhythm control where appropriate,Diagnosis,AF can only be diagnosed on an ECG recorded during symptoms/signsEven asymptomatic patients should have an ECGConsider 24 hour to 7 day Holter if intermittent(depending on frequency)Or ask patient to attend A+
5、E during symptoms and get a copy of ECG,Investigation,TFTEchoIf youngIf rhythm control strategyIf unsure of stroke riskIf structural heart disease suspected,Stroke prevention,Warfarin(INR 2-3),Aspirin,Rate control vs rhythm control,RACEMortality 22.6%vs 17.2%39%vs 10%in SR AFFIRMMortality 23.8%vs 21
6、.3%hospitalisation Side effectsSR 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,Treatment decision tree,Advantages of Warfarin over Aspirin,Advantages
7、of Warfarin over Aspirin,rhythm vs rate control,Persistent AF rate control,Specialist referral,Rhythm control,Rate control vs Rhythm control,AF is dangerousSR is better and confers mortality benefit Conventional therapies are poor at maintaining SR The population is aging,What specialist treatments
8、are available?,Antiarrhythmic drugsPacemakerCatheter ablationSurgical ablation,AV node ablation and pacing,AV node ablation and pacing,“hides”the AFEasy to perform(99%)successNo atrial transport(turbo)Pacing dependent(LBBB)No going backRefuge of the elderly and desperate,The first curative procedure
9、 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 AF,Target PV trigger,LIMITED BY:Absence of spontaneous ectopyMultiple triggers,Focal A
10、F: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 stylisedAccurate lesion location is very dependent on experience,CT integration,True 3-dimensional
11、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,Practicalities of curative AF ablation,Pre op-CT few weeks pre-opTOE on dayACT 300 during procedureProce
12、dure time 2-3 hours PAF/3-4 hours PersistentPost-op echoWarfarin loading on night of procedureContinues for 3 months if low riskEnoxaparin day after until INR2,Case Control Study of 3-D mapping vs CT integration,105 patients6 month follow up7 day holter at 3 monthsSimilar operator profile and experi
13、ence,AF ablation results,Freedom from AT/AFoff medication at 6 month follow up,CT integration(n=53),3D mapping(n=52),P value,Complications of AF ablation,2%pericardial effusion/tamponade3%Femoral haematoma0.5%stroke/TIA0.5%PV stenosis,Recurrence,Usually occurs 3months(late recurrence is rare)May set
14、tle over a 3 to 6 month periodResults in 28%to 40%of patients requiring redo,How does ablation compare to drugs?,Ablation vs drugs,Does ablation improve prognosis?,Pappone et al circulation 2001,Complications of AF ablation,AF ablation is good for your garden,AF ablation for heart failure,Patients w
15、ith EF45%and AFRandomised to medical therapy or med therapy and catheter ablation21 patients enrolled so far15 patients with at least 1 month FU7 Catheter Ablation8 Medical,Preliminary results,2 pts recurrence after ablation awaiting redo6pts improved 1 NYHA5%EF after 1 month,Who should have AF abla
16、tion,Symptomatic(incl heart failure?)Persistent AF for 5 yearsPrepared to go through multiple proceduresPrepared for the risks,Limitations of AF ablation,High volume does make a differenceRedos are commonTarrif does not reflect costSerious complications are increasingly rare but do occurTeam work is critical,Conclusion,AF is commonPriorities for treatment now clearly definedCure is now possible but at a costThe“lost tribe”of AF sufferers now have hopeThe epidemic may have a,
