audit of ablation procedures for af barts and the london
TRANSCRIPT
Audit of ablation procedures for AFAudit of ablation procedures for AF
Barts and The London
AF burdenAF burden
• Framingham
– Lifetime risk of developing AF = 25%
– Mortality: SMR =1.9 ♀ 1.5 ♂
• NHS audit
– 1% of budget spent on AF
• ↓↓Quality of life
– Symptoms of AF
– Side effects of medication
Benjamin, E. 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
Are effective treatments available?Are effective treatments available?
• Antiarrhythmic drugs
– Toxicity: AFFIRM
– No benefit over rate control
– SR has a prognostic benefit
• Rate control and anticoagulation
– As good as AADs:
• Prognosis
• QOL
– Ximelagatran
Non pharmacological methodsNon pharmacological methods
• Pacemaker
– Pace to suppress triggers of AF
– Multisite or biatrial pacing
• Atrial defibrillators
• Surgical ablation
• Catheter ablation
Mechanisms of AFMechanisms of AF
Ablation strategiesAblation strategies
Isolation/destruction of triggers:
•Target pulmonary vein isolation (PVI)
•Total PVI ± other triggers
Modification of atrial substrate:
•Linear lesions in left atrium, right atrium or both
•Wide circumferential lesions around pulmonary veins
•Catheter maze
Left atrial maze and PVI
Pulmonary vein isolationPulmonary vein isolation
Linear ablation in the left atriumLinear ablation in the left atrium
Catheter mazeCatheter maze
Standards from published dataStandards from published data
Procedure Centre/Date NPermanent
AF %Complication
rate %
Repeat Procedures
%
Maintenance of SR %
LA linear ablation
KuckHamburg 1999
84 23 6 -74
(if lines complete)
WACAPappone
Milan 2001 251 27 0.8 -
85 PAF68 Permanent
4 PVIHaisaguerre
Bordeaux 2002136 10 0.7 49
81(66 off drugs)
Worldwide survey of AF ablationCappato et al. ESC 2004
Worldwide survey of AF ablationCappato et al. ESC 2004
• Data from 777 centres
• Number of cases– 18 in 1995, 5050 in 2002
– Median of 37.5 cases per centre (range 1-600)
• Commonest procedure– 1995-97 Right atrial maze
– 1998-99 Target PVI
– 2000-02 Electrical disconnection of all PVs
• Outcomes– 8745 pts in 90 centres
– 27.3% >1 procedure
– 76% asymptomatic (24% on antiarrhythmic drugs)
– 6% major complication rate
St Bartholomew’s dataSt Bartholomew’s data
• PATS database (EP and EP2)
• Research database
– Catheter maze study
– Coarse AF study
• Patient letters
– DMS/EPR viewer
• Telephone patients
Total number of proceduresTotal number of procedures
0
5
10
15
20
25
30
35
Catheter
maze
LA maze +
PVI
Total PVI RA isthmus WACA PV LA flutter Target PVI RA maze
100 procedures in 73 patients
Increasing number of proceduresIncreasing number of procedures
6
21
36
46
0
510
1520
2530
35
4045
50
2001 2002 2003 2004
PatientsPatients
N=73 50±8 years 58M 15F
Normal
74%
Other
7%DCM3%
Hypertensive16%
Cardiac diagnosis:
Paroxysmal49%
Persistent3%
Permanent48%
Type of AF:
Outcomes: improvement in symptoms?Outcomes: improvement in symptoms?
0%
20%
40%
60%
80%
100%
Overall Paroxysmal AF Permanent
Resolved Some improvement No improvement
Outcomes: maintenance of sinus rhythm?Outcomes: maintenance of sinus rhythm?
0%
20%
40%
60%
80%
100%
Overall Paroxysmal AF Permanent
Sinus rhythm AF
Need for antiarrhythmic drugs?Need for antiarrhythmic drugs?
0%
20%
40%
60%
80%
100%
Overall in SR PAF in SR PermanentAF in SR
Overallsymptomsimproved
PAFsymptomsimproved
PermanentAF
symptomsimproved
No drugs On drugs
Need for repeat procedures?Need for repeat procedures?
0%
20%
40%
60%
80%
100%
Symptoms improved Currently in SR
1 2 3
Number of procedures per patient:
Success of 1st procedureSuccess of 1st procedure
0%
20%
40%
60%
80%
100%
Cathetermaze n=23
4 veinisolation
n=9
WACAcarto n=9
LAmaze_PVI
n=4
RAisthmus
n=9
Symptoms improved In SR
Paroxysmal >1 Procedure needed
Procedure timesProcedure times
0
100
200
300
400
Procedure Time Screening time
Mins 281±120
49±25
ComplicationsComplications
• Major n=4 (4.5%)
– 2 Tamponade
– 1 Stroke
– 1 Severe PV stenosis
• Up to June 03 (11.4%)
• Since July 03 (0%)
• Minor n=7 (8.0%)
– 2 transient ST elevation
– 2 mild PV stenosis
– 1 tip of active fix pacing wire in RA
– 2 haematoma
Catheter maze studyCatheter maze study
• Baseline characteristics:
– 23 patients (19M 4F)
– 49 ± 9 years
– AF duration 4 ± 3 years(11 ± 9 months continuously)
– 2.7 ± 1.7 DCCV
– 3.3 ± 1 antiarrhythmic drugs
– LA diameter 4.9 ± 0.9 cm
• Mean follow up 10±7 months
Catheter maze outcomeCatheter maze outcome
9 + 2*
8
3
4
9
14
Index Catheter MazeN=23
AF or AFL recurrence
Medium termSinus rhythmN=17 (77%)
PermanentAF accepted
N=3
Repeat ablation
* In AF awaitingfurther treatment
N=2
1 death fromunrelated cause
2nd or 3rd
AF or AFL recurrence
2
4
1
Results: symptoms and QOLResults: symptoms and QOL
Baseline
SR
-6 ± 7+14 ± 1.46 months
change vs 6 weeks
-34 ± 24*-6 ± 376 weeks
change vs baseline
-58 ± 29
Modified Karolinska
(0-140)
*P < 0.05
AF or AFL
Surgical Maze – BRACUS stidySurgical Maze – BRACUS stidy
• Bipolar Radiofrequency Ablation for Chronic atrial fibrillation in patients Undergoing mitral valve Surgery
Patient Diagnosis Operation Date Rhythm at follow up
65 ♀MR due to
RhVD MVR + TV annulplasty June 04 Atrial flutter
71 ♀MR due to
MVPMV and TV repair and
annulplastyJune 04 SR
68♂MR due to
MVPMVR Aug 04 (AF)
ConclusionsConclusions
• Clinical need for improved pharmacological or non pharmacological treatments for AF
• AF ablation at St Bartholomew’s is effective and at a level with published data
• Low but important complication rate
St Bartholomew’s as a lead national centre for AF ablation
St Bartholomew’s as a lead national centre for AF ablation
• Increasing number of cases
• Prospective symptom, QOL and rhythm collection
• Publishing and presenting our data
• Research• Catheter Maze
• Coarse AF
• BRACUS
• Training
• Centre of excellence for industry• Ensite NavX 4.0 and 5.0
• Digital Image fusion