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1、Treating Atrial FibrillationRichard SchillingAF 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 medicationBenjamin,E.J.et al.Impact of atrial fibrillation on the risk of dea
2、th: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 Nice guidance for management of AF Issued on June 2006 Aimed to give a UK based simple guidance on management of AF
3、Attempts to be evidence based And applicable to the majority of patientsKey aims of management Diagnosis-everyone with irregular pulse gets ECG Identify secondary causes(thyroid,hypertension,valve disease)Treatment Stroke prevention Rate control Rhythm control where appropriateDiagnosis AF can only
4、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(depending on frequency)Or ask patient to attend A+E during symptoms and get a copy of ECGInvestigation TFT Echo If young If rhythm control strategy If
5、unsure of stroke risk If structural heart disease suspectedStroke preventionWarfarin(INR 2-3)AspirinRate control vs rhythm control RACE Mortality 22.6%vs 17.2%39%vs 10%in SR AFFIRM Mortality 23.8%vs 21.3%hospitalisation Side effects SR has a prognostic benefitRhythm control-problem Cardioversion and
6、 drugs maintains SR in 42%at one year(amiodarone)Side effects require stopping amiodarone in 25%Anticoagulation stopped too earlyTreatment decision treeAdvantages of Warfarin over AspirinAdvantages of Warfarin over Aspirinrhythm vs rate controlPersistent AF rate controlSpecialist referralRhythm cont
7、rolRate control vs Rhythm control AF is dangerous SR is better and confers mortality benefit Conventional therapies are poor at maintaining SR The population is agingWhat specialist treatments are available?Antiarrhythmic drugs Pacemaker Catheter ablation Surgical ablationAV node ablation and pacing
8、AV node ablation and pacing“hides”the AF Easy to perform(99%)success No atrial transport(turbo)Pacing dependent(LBBB)No going back Refuge of the elderly and desperateThe first curative procedure MazeJL Cox et al 1991Why does the maze work?Radiofrequency Ablation CatheterLesion cross-sectionHow is RF
9、 energy appliedRFA Lesion-MacroscopicAtrial fibrillation originates in the left atriumMechanisms for AFTarget PV triggerLIMITED BY:Absence of spontaneous ectopyMultiple triggersFocal AF:RFA to“disconnect”PV potentialContinuous circular lesionsCatheter ablation in permanent AFEarley et al.Heart 2005M
10、V31/41(76%)in SR at 8.4 mthsThe electroanatomical approach The anatomy is very stylised Accurate lesion location is very dependent on experienceCT integrationCreating 3 landmark pairsLPV locations of interestLPV internal viewDoes this have a clinical effect?LUPVLAALLPVAblation linesIsolation of LPVs
11、 during AFPracticalities 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 INR2Case Control Study o
12、f 3-D mapping vs CT integration 105 patients 6 month follow up 7 day holter at 3 months Similar operator profile and experienceAF ablation results 3D mapping(n=52)CT integration(n=53)P valuePatient characteristics Age(years)54 1158 9NSParoxysmal/Permanent AF23/2925/28NSAF duration(years)5.3 5.56.7 5
13、.7 Number of failed meds2.8 0.62.7 1.1NSLA size(mm)46 644 5NSLV end diastolic volumes50 352 5NSNS Paroxysmal71%94%0.17Permanent50%73%0.20Overall 59%82%0.05Follow Up(weeks)25 1125 8NSFreedom from AT/AFoff medication at 6 month follow upCT integration(n=53)3D mapping(n=52)P valueComplications of AF ab
14、lation 2%pericardial effusion/tamponade 3%Femoral haematoma 0.5%stroke/TIA 0.5%PV stenosisRecurrence Usually occurs 3months(late recurrence is rare)May settle over a 3 to 6 month period Results in 28%to 40%of patients requiring redoHow does ablation compare to drugs?Ablation vs drugsDoes ablation im
15、prove prognosis?Pappone et al circulation 2001AblationN=589MedicalN=582Death3883Adverse events54117Complications of AF ablationAF ablation is good for your gardenAF ablation for heart failure Patients with EF1 NYHA 5%EF after 1 monthWho should have AF ablation Symptomatic(incl heart failure?)Persist
16、ent AF for 5 years Prepared to go through multiple procedures Prepared for the risksLimitations of AF ablation High volume does make a difference Redos are common Tarrif does not reflect cost Serious complications are increasingly rare but do occur Team work is criticalConclusion AF is common Priorities for treatment now clearly defined Cure is now possible but at a cost The“lost tribe”of AF sufferers now have hope The epidemic may have a
