Pierre Jaïs, MD, Bordeaux, FrancePierre Jaïs, MD, Bordeaux, France

LIRYC, MUSICLIRYC, MUSIC

IHU LIRYC IHU LIRYC ANR-10-IAHU-04ANR-10-IAHU-04

Equipex MUSIC ANR-11-EQPX-0030Equipex MUSIC ANR-11-EQPX-0030

FP 7 grant: FP 7 grant: HEALTH-F2-2010-261057Stock Holder Cardio InsightStock Holder Cardio Insight

Consultant for BWConsultant for BW

Lecture honoraria: SJM, Bard, Philips, Boston Scientific Lecture honoraria: SJM, Bard, Philips, Boston Scientific

Impact de l’ablation IVP Impact de l’ablation IVP sur la décompensation sur la décompensation

cardiaquecardiaqueet le risque d’AVC. Quelles et le risque d’AVC. Quelles

promesses ont été promesses ont été remplies?remplies?

Bruxelles 29 Nov 2014

AF and HF

• AF is present in 15 to 30 % of HF patients

• NYHA I: 10% of AF

• NYHA IV: 50% of AF! (Stevenson, AJC 03)• AF is associated with 1.5 to 3 fold death in

HF patients (Benjamin, Circ 98; Krahn, Am J Med, 95)

Sinus Rhythm or AF?Sinus Rhythm or AF?

Data from AFFIRM, RACE, PIAF, suggests no difference between pharmacological rate or rhythm control.However, effect of sinus rhythm without the deleterious effects of drugs was not evaluated

Data from AFFIRM, RACE, PIAF, suggests no difference between pharmacological rate or rhythm control.However, effect of sinus rhythm without the deleterious effects of drugs was not evaluated

AFFIRM Substudy (Epstein, Circulation 2004) • Sinus rhythm: 47% reduction in mortality risk• Use of antiarrhythmics: 49% increase in mortality risk• CHF: 57% increase in mortality risk

AFFIRM Substudy (Epstein, Circulation 2004) • Sinus rhythm: 47% reduction in mortality risk• Use of antiarrhythmics: 49% increase in mortality risk• CHF: 57% increase in mortality risk

Persistent AF and HF,therapeutic options

• 1- AAD (limited) and DC shocks

• 2- Rate control

– Pharmacological

– AVN ablation + CRT (P or D)

• 3- AF Ablation

AF Ablation in 86 HF patients

Male 77 (89%)

Age (years) 56±10

Persistent/Permanent AF 79 (92%)

Duration of AF (months) 80±46

Coexisting heart disease 44%

ABLATION METHOD FOR CHRONIC AF

LSPV

LIPV

RSPV

RIPV

LAA

1. PV 2. Roof

3. Inf LA-CS

4. Organising atrial activityLAA/Ant LA Septum Post LA

5. MI Line

FO

CS

Types of Atrial Electrograms TargetedTypes of Atrial Electrograms Targeted

CONTINUOUS

RAPID Local CL<REF

FRACTIONATEDRFd

RFp

Dcs

Pcs

RFd

LAA

RAA

RFd

LAA

RAA

RFd

RFp

Jais, PACE 1996

Nademanee, JACC 2004

ACTIVATION GRADIENT

Procedural Outcome

Redo Procedures 48%

Sinus rhythm (overall) 81%

Sinus rhythm without drugs 73

Duration of follow-up (months) 14±7

Major complications• Tamponade• Stroke

5%2.5%

2.5%

LV Ejection Fraction

20

30

40

50

60

70

0 1 3 6 12

Months

LV

EF

(%)

Average increase in LVEF = 21% (p<0.001)

Change in LVEF (Individual)

10

20

30

40

50

60

70

80

LVEF

(%)

Baseline Final (12±7 months)

36±7%

57±12%

11

12

13

14

0 11±7

Exercise TimeExercise Time

MonthsMonths

P=0.007P=0.007

minmin

125

130

135

140

145

0 11±7

Max Power AttainedMax Power Attained

MonthsMonths

P=0.03P=0.03

WW

Improvement Exercise Capacity In CHFImprovement Exercise Capacity In CHF

Based on 58 pts published in NEJM 2004; 351, 2373-83

25

30

35

40

45

50

55

60

65

70

0 12±7

Months

LV E

ject

ion

Frac

tion

(%)

P<0.001

P<0.001

Poor Rate Control+23±10 %

Adequate Rate Control+17±15 %

25

30

35

40

45

50

55

60

65

70

0 12±7

Months

LV E

ject

ion

Frac

tion

(%)

P<0.001

P<0.001

No concurrent heart disease+24±10 %

Concurrent heart disease+16±14 %

Rate control Heart Disease

Marked improvement (by 20% or to ≥ 55% EF)

Poor rate control: 86%Adequate rate control: 54%

No concurrent HD: 88%W/ concurrent HD: 54%

92%

Based on 58 pts published in NEJM 2004; 351, 2373-83

WORKFLOW

CardioInsight®

100 200 300 400 500 600 700-0.06-0.04-0.0200.020.04

433

100 200 300 400 500 600 700-0.05

00.05

434

100 200 300 400 500 600 700-0.05

00.050.1

424

100 200 300 400 500 600 700

-0.050

0.050.1

348

100 200 300 400 500 600 700-0.1

00.1

342

100 200 300 400 500 600 700

-0.050

0.05

341

100 200 300 400 500 600 700-0.05

00.05

340

100 200 300 400 500 600 700

-0.050

0.05

411

100 200 300 400 500 600 700

-0.1-0.05

00.05

421

100 200 300 400 500 600 700

-0.1-0.05

00.05

432

100 200 300 400 500 600 700-0.06-0.04-0.0200.020.04

433

100 200 300 400 500 600 700-0.05

00.05

434

100 200 300 400 500 600 700-0.05

00.050.1

424

100 200 300 400 500 600 700

-0.050

0.050.1

348

100 200 300 400 500 600 700-0.1

00.1

342

100 200 300 400 500 600 700

-0.050

0.05

341

100 200 300 400 500 600 700-0.05

00.05

340

100 200 300 400 500 600 700

-0.050

0.05

411

100 200 300 400 500 600 700

-0.1-0.05

00.05

421

100 200 300 400 500 600 700

-0.1-0.05

00.05

432

Patient Specific GeometryPatient Specific Geometry

252-electrode Body Vest252-electrode Body Vest

AF Interval 1

AF Interval N

Cumulative map

Effect of PVI on LV EF67/366 (18%) pts with baseline EF ≤ 50% and

“controlled” ventricular rate (<90 bpm)

0

10

20

30

40

50

60

70

80

LVEF Baseline LVEF Follow up

LV

EF

44%

57%

Gentlesk, Marchlinski et al, JCE in press

LV EF increased by > 5% in 82% patients LV EF normalized to ≥ 55% in 72% patients

70% Parox AF27% SHD

Long-term follow-up after atrial fibrillation ablation in patients with impaired left ventricular systolicfunction:

The importance of rhythm and rate control S Nedios… C Piorkowski…Andreas Bollmann… Gerhard Hindricks

Heart Rhythm2014;11:344–351

69patients, LVEF <40%PVI ± substrate ablation28 ±11 months 1.6 ± 0.7 ablation procedures45(65%) patientsIn stable sinus rhythm (SSR)

Initial improvement in LVEF is rate dependant, but not after 6 mo

Boris A. Lutomsky … Stephan WillemsEuropace (2008) 10, 593–599

70 pts paroxysmal AF MR @ 6 mo for LVEF

41+6 vs. 51+12%, P = 0.004

AF Ablation in 72 pts (40% parox)36 low EF and 36 normal (41.4+8.0 vs. 63.1+5.5%)

PABA NEJM 2008; 359: 17

1.Curative ablation of AF is feasible but difficult in patients with CHF and coexisting heart disease

2. It results in dramatic improvements in symptoms, exercise capacity and quality of life

3. This therapeutic approach is possibly the best one in first intention in patients with idiopathic dilated CMP and AF. It can be completed by CRT (D) in absence of improvement

1.Curative ablation of AF is feasible but difficult in patients with CHF and coexisting heart disease

2. It results in dramatic improvements in symptoms, exercise capacity and quality of life

3. This therapeutic approach is possibly the best one in first intention in patients with idiopathic dilated CMP and AF. It can be completed by CRT (D) in absence of improvement

Conclusion

4- Even in the context of SHD, or controlled heart rate, AF ablation can be associated with LVEF improvement

5- The LVEF improvement is more pronounced in Persistent vs Paroxysmal AF

6- This improvement is not just mediated by a decreased heart rate

4- Even in the context of SHD, or controlled heart rate, AF ablation can be associated with LVEF improvement

5- The LVEF improvement is more pronounced in Persistent vs Paroxysmal AF

6- This improvement is not just mediated by a decreased heart rate

Conclusion

Cappato et al,Circulation 2005

Rate for embolic events related to AF ablation

In the literature: 0-7%

Multicenter studies

Name N(abl) Type of AF strokes AV-Block

PABA-CHF 41 P and P 0 0

A4 53 Parox 0 0

CPVA 77 Persist 0 0

Stabile 68 P and P 1 (1.3%) 0

RAAFT 33 Parox 0 0

1. Warfarin is recommended for all patients for at least two months following an AF ablation procedure,

2. Decisions regarding the use of warfarin more than two months following ablation should be based on the patient’s risk factors for stroke and not on the presence or type of AF.

3. Discontinuation of warfarin therapy post ablation is generally not recommended in patients who have a CHADS score ≥ 2.

After ablation

755 pts ablated, 490 parox, 265 persitent, PVI + CAFE34 (5%) had previous TEs

Circ 2006;114:759-765

256 patients remained in sinus rhythm wo risk factors for stroke, anticoagulation wasdiscontinued in 203 (79%) at a median of 4 months

266 patients in sinus rhythm and had 1 risk factor, anticoagulation was discontinuedin 180 (68%) at a median of 5 months

TEs occurred in 7 of 755 patients (0.9%) within 30 daysAnd in 2 (0.3%) beyond 30 days after the procedure

A cerebral hemorrhage occurred in 2 patients (0.3%) whowere in AF and were being treated with warfarin 1 and 3months after LARFA. One patient was 70 years old and hadan INR of 3.5 and the other patient was 53 years old and hadintracranial bleeding after head trauma.

Ablation: PVI + SVCCAFE in Persistent AFIso in all

24 H Holter7 days whenever possible

3,355 patients, 2,692 (79% male, mean age 57 ± 11 years) discontinued OAT 3 to 6 months after ablation 663 (70% male, mean age 59 11 years) remained on OAT after this period CHADS2 of 1 and 2 in 723 (27%) and 347 (13%) Off-OAT 261 (39%) and 247 (37%) On-OAT group patients, respectively.

Incidence of Late Thromboembolic Events AfterCatheter Ablation of Atrial Fibrillation

Atsuhiko Yagishita, MD; Yoshihide Takahashi, MD; Atsushi Takahashi, MD; Akira Fujii, MD;Shigeki Kusa, MD; Tadashi Fujino, MD, PhD; Toshihiro Nozato, MD, PhD;Taishi Kuwahara, MD; Kenzo Hirao, MD, PhD; Mitsuaki Isobe, MD, PhD

524 ptsParox 69%Persistent 31%FU 44± 13 mo

Botto, JCE; Vol. 20, pp. 241-248, March 2009

Botto, JCE; Vol. 20, pp. 241-248, March 2009)

Discontinuing anticoagulation following successful atrialfibrillation ablation in patients with prior strokes

Roger A. Winkle & R. Hardwin Mead & Gregory Engel &Melissa H. Kong & Rob A. Patrawala

J Interv Card Electrophysiol (2013) 38:147–153

108 patients with a history of prior thromboembolic CVA/TIA

Ablation Protocol and FU

• PVI and roof line in all

• CAFE in persistent and long standing

• Mitral and CT isthmus if needed

• Interrupted Warfarin

• 7/21 days Holter monitoring

• OAC interrupted @ 7,3 mo

• follow-up after discontinuation of OAC averaged 2.2±1.3 (median=1.8) years.

Discontinuing anticoagulation following successful atrialfibrillation ablation in patients with prior strokes

Roger A. Winkle & R. Hardwin Mead & Gregory Engel &Melissa H. Kong & Rob A. Patrawala

565 AF AblationsFU 40 mo27 pts (4,8%) TE events or death9 death, 9 strokes, 6 TIA

Cauchemez et al, JCE 2004

Cauchemez et al, JCE 2004