Niraj Sharma, MD• Electrophysiologist at

CardioVascular Group/Gwinnett Medical Group

• Board Certified in Internal

Medicine, CardiovascularDiseases, and Electrophysiology

• Special interests include treating patients with abnormal heart rhythms, and ablation of arrhythmias, including atrial fibrillation.

Medical School:Medical College Jabalpur

Residency: Brown University

Fellowship: Univ. of Texas

Southwestern Medical Center

Niraj Sharma MD FACC FHRS

Gwinnett Health system

Atrial Fibrillation introduction and a little bit beyond…

You see a patient in the hospital and determine she needs warfarin. She does not want to take “rat poison” and asks you how effective it is.You quote warfarin efficacy (based on meta-trial data) as:A. 65% effective in ischemic stroke reductionB. 80% effectiveC. 90%D. 55%

Question # 0

A) 65%

Answer # 0

45 year old female hiker with symptomatic (palpitation) pAF has episodes lasting 3 days at a time. She has no other medical history. Based on the CHADSVASC score you will:A. AC with warfarinB. AC with Novel ACC. No ACD. Aspirin

Question # 1

C) No AC # 3

CHADSVASC score of 0 (female by itself is 0)

Answer # 1

CHADSVASC vs CHADS

60 year old male with asymptomatic permanent AF, with diabetes. Based on CHADSVASC score you would:A. AC with either Warfarin or NOACB. AspirinC. No ACD. Any of the above

Question # 2

D) current guidelines (CHADSVASC 1, if female than 2)….USA (AC in Europe)

More recent evidence suggests # 1 (AC) per Lip or #3 as per Friberg

Answer # 2

Relationship of stroke risk and AF duration is:A. Linear progressionB. Sigmoidal riskC. Log-rhythmicD. Stroke risk not assessed by duration

Question # 3

D) No relation

Assessment of stroke risk does not take into account duration

This is different if DCCV being planned

Answer # 3

78 year old male with DM, HTN, prior CVA presents to the ER at 11pm with new onset AF (started at 9pm while watching dancing with the stars) with RVR and has exertional SOB. Exam apart from AF, is unremarkable. You would:A. DCCV: because AF is <48 hours and the pt is

symptomaticB. TEE and then DCCVC. Rate control first, start AC and DCCV in 3-4

weeks D. Call Cardiology

Question # 4

C) Rate control first, start AC and DCCV in 3-4 weeks

CHADSVASC score does not have a role in evaluation stroke risk in patients undergoing DCCV

Caution while assessing 48 hour windowSymptomatic AF tip of iceberg

Answer # 4

76 year old female with confirmed “mildly” symptomatic AF and CHADSVASC score of 5 (female, HTN, DM, age) presents to your office. She is currently in AF and her vitals are: BP 148/88 P: irreg 90/min, other exam is unremarkable. The best option is:A. Start AC and initiate AAD treatment to reduce

episodes of AF and keep her in SRB. Start AC C. Start AC and get 24 hr Holter for VR controlD. AC for 3 weeks and DCCV and reassess

symptoms

Question # 5

D) AC for 3 weeks and DCCV and reassess symptoms

AFFIRM

Answer # 5

Dabigatran should NOT be used with which AAD?A. DronedaroneB. FlecanideC. SotalolD. DofetalideE. 1 and 4F. 1, 3 and 4G. 2 and 4

Question # 6

?Combination CI in EuropeCombination of Dabigatran and Dronedarone

increased blood levels of Dabigatran and increases risk of bleeding

Answer # 6

84 year old male with long standing persistent AF, DM, HTN, CABG, MV repair and ESRD on HD.The choice of AC is:A. ApixabanB. RivaroxabanC. WarfarinD. Dabigatran

Question # 7

C) Warfarin

MV repair= Valvular AF

Answer # 7

28 year old male with AF and incidental diagnosis of hypertrophic CMP on Echo done at PCP’s office for a murmur. He is referred to you for risk assessment. You would recommend:A. No AC CHADSVASC score of 0B. WarfarinC. ApixabanD. ASAE. B or C

Question # 8

E) B or C

HOCM is = CHADSVASC of 2Not considered “Valvular” AF

Answer # 8

Most common sustained rhythm problemMajor disease with 2.6million people in 2010

and projected be 12.5million in 2050Mortality rate with AF as primary or

secondary diagnosis increasing over the last 2 decades

Morbidity a major concern: 15-20% of ischemic strokes

Major economic burden to the patient as well as Healthcare

Why are we talking about “just” one disease?

Most common sustained rhythm problemMajor disease with 2.6million people in 2010

and projected be 12.5million in 2050Mortality rate with AF as primary or

secondary diagnosis increasing over the last 2 decades

Morbidity a major concern: 15-20% of ischemic strokes

Major economic burden to the patient as well as Healthcare

Why are we talking about “just” one disease?

EPIDEMIOLOGY

• The most prevalent sustained rhythm disorder

• Accounts for 1/3 of hospitalisations due to cardiac rhythm disturbances

• Estimated prevalence in USA 2.6 and worldwide 5.5 million

Arrhythmia-related hospitalisations

in the US

Atrial flutter 4% Paroxysmal

supraventriculartachycardia 6%

Atrial fibrillation

34%

Ventricular fibrillation

2%

Ventriculartachycardia

10% Miscellaneous 21%

Conductionabnormalities 8%

Sick sinussyndrome 9%

Prematurebeats 6%

AFib is responsible for a 5-fold increase in the risk of ischemic stroke

AFib is Responsible for 15-20% of all Strokes

Wolf PA, et al. Stroke (1991) 22: 983Go AS, et al. JAMA (2001) 285: 2370Friberg J, et al. Am J Cardiol (2004) 94: 889

12

02

8

4

41 53 2 41 53

Cu

mu

lati

ve s

troke in

cid

en

ce (

%)

Women AFib+

Women AFib-

Men AFib+

Men AFib-

Years of follow-up

Men 1.5x more then womenLess common in AA12% 75-84: 1% <60yrsTall (increase atrial size)/Obese (DM,OSA,

HTN, Systolic as well as diastolic dysfunction)Genetic rareAthletic lifestyle (high vagal tone)Cigarette smoking/Alcohol abuse

Epidemiologic data

Medicare Data

Classification

1. Paroxysmal AF- episode that spontaneously terminates in 7 days (~40% terminate in 24 hours)- minimal atrial scar most amenable to ablation i.e. stops by itself

2. Persistent AF- episode that lasts >7 days or requires cardioversion i.e. requires intervention

3. Permanent AF- fails to terminate with cardioversion or terminates and relapses within 24 hours- most amount of atrial scar least amenable to AAD or ablation i.e. end stage

ACC/AHA/HRS

ACC/AHA/HRS: Rheumatic MV disease, prosthetic valve or repair

ACCP: MS, prosthetic valveESC: Rheumatic valve disease, prosthetic

valveTrial definitions:

Valvular vs. non-valvular AFGuidelines

Valvular AF and trials

New Clasification

AF PathophysiologyCircRes.2014;114:1453-1468

CircRes.2014;114:1453-1468

Mechanism of AF

Knowing the risk of stoke is essentially similar in AF and in Atrial flutter, what would you prefer to have?A. AFB. Atrial flutter

Question # 9

B) Atrial flutter

Answer # 9

Mechanism of Atrial Flutter

Difference betweenFlutter and Fibrillation

1. Single large reentrant circuit in the RA

2. Difficult to rate control and usually not paroxysmal

3. Ablation first line of treatment

4. Ablation success >90-95%

5. Minimal risk for ablation6. AC can be stopped after

ablation if no associated AF

1. Multiple small foci in and around Pulmonary veins

2. Starts off as paroxysmal; easier to rate control

3. Ablation if AAD fail4. Ablation success 70-80%

for paroxysmal 60% for all

5. Can have serious complications

6. AC continued after ablation if risk factor ≥2

Ablation Line across the CTI

Treatment Options for AFib

Cardioversion

• Pharmacological

• Electrical

Drugs to prevent Afib (tomorrow)

• Antiarrhythmic drugs

Drugs to control ventricular rate (tomorrow)

Drugs to reduce thromboembolic risk (Dr Gangasani)

Non-pharmacological options

• Electrical devices (implantable pacemaker and defibrillator)

• AV node ablation and pacemaker implantation (ablate & pace)

• Catheter ablation/Hybrid ablation (Dr Harvey)

• Surgery (Maze, mini-Maze) (Dr Harvey)

• LAA closure devices: Lariat, Watchman (Dr Unterman)

When and Why Acutely Cardiovert?

AF Begets AF

AF causes changes in atrial electrophysiology that promote AF maintenance

Wijffels Circulation 1995; 92: 1954-68

In the ER you are consulted for new onset AF, started last night, with IV diltiazem controlled VR and now asymptomatic. The ER doc wants to DCCV and send home. AC is started. You would:A. Agree with herB. ED obs and DCCV in amC. TEE and DCCV in ER

Question # 10

# 2

Answer # 10

Likelihood of Spontaneous Conversion of Atrial Fibrillation to Sinus Rhythm

Danias J Am Coll Cardiol. 1998;31:588-92

• 356 pts with AF < 72 h• Symptoms of < 24 h was only independent predictor of

spontaneous conversion (OR: 1.8, p < 0.0001)

< 24 h

24 - 72 h

Total

292

64

356

73%

45%

68%

AF duration n Conversion

Cardioversion of atrial flutter and fibrillation after ibutilide infusion

Stambler Circulation. 1996;94:1613-1621

Predictors of Cardioversion with Ibutilide201 patients treated

Zaqqa AJC 2000

Oral NEJM 1999;340:1849-54

100 consecutive patients 50 assigned conventional

DC 50 pretreated with 1 mg

ibutilide

Card

iove

rsio

n s

ucc

ess

(%

)

Maintenance of Sinus Rhythm

Medicate or Ablate or Status quo

Treatment Options for AFib

Cardioversion

• Pharmacological

• Electrical

Drugs to prevent AFib

• Antiarrhythmic drugs

Drugs to control ventricular rate

Drugs to reduce thromboembolic risk

Non-pharmacological options

• AV node ablation and pacemaker implantation (ablate & pace)

• Catheter ablation/Hybrid ablation

• Surgery (Maze, mini-Maze)

Cardioversion

AFFIRMBaseline Characteristics

Age = 69.7 ± 9.0 yrs 39% female > 2 days of AF in 69% CHF class > II in 9% Symptomatic AF in 88%

Trials of Rate vs Rhythm Control

ACC/AHA/HRS Guidelines

Implications of Trials: Guideline Statement

Theoretically, rhythm control should have advantages over rate control, yet a trend toward lower mortality was observed in the rate-control arm of the AFFIRM study and did not differ in the other trials from the outcome with the rhythm control strategy. This might suggest that attempts to restore sinus rhythm with presently available antiarrhythmic drugs are obsolete. The RACE and AFFIRM trials did not address AF in younger, symptomatic patients with little underlying heart disease, in whom restoration of sinus rhythm by cardioversion antiarrhythmic drugs or non-pharmacological interventions still must be considered a useful therapeutic approach. One may conclude from these studies that rate control is a reasonable strategy in elderly patients with minimal symptoms related to AF. An effective method for maintaining sinus rhythm with fewer side effects would address a presently unmet need.

ACC/AHA/HRS Guidelines

Maze reproduction Schwarz 1994

Right atrial linear lesions Haïssaguerre 1994

Right and left atrial linear lesions Haïssaguerre 1996

PV foci ablation Jaïs / Haïssaguerre 1997/8

Ostial PV isolation Haïssaguerre 2000

Circumferential PV ablation Pappone 2000

Ablation of non-PV foci Lin 2003

Antral PV ablation Maroucche / Natale 2004

Double Lasso technique Ouyang / Kuck 2004

CFAE sites ablation Nademanee 2004

Ostial or circumferential or antral PV ablation plus extra lines (mitral isthmus, posterior wall, roof)

Jaïs / Hocini 2004/5

Circumferential PV ablation with vagal denervation

Pappone 2004

Technique Publication date

Landmarks in Catheter Ablation Techniques

Linear 443 75% 26% 33% 55%

Focal 508 81% 35% 54% 71%

Isolation 2,187 83% 36% 62% 75%

Circumferential (all) 15,455 68% 37% 64% 74%

Circumferential (LACA, WACA) 2,449 65% 37% 59% 72%

Circumferential (PVAI) 11,132 68% 42% 67% 76%

Substrate ablation (CFAE) 559 51% 49% 75% 87%

TOTAL 23,626 61% 55% 63% 75%

PatientsParoxysma

l AF 6-month cure 6-months OKAblation method SHD

Fisher JD, et al. PACE (2006) 29: 523

Meta-analysis of Catheter Ablation

Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of AAD.OK means improvement (fewer episodes, no episodes with previously ineffective AAD).SHD indicates structural heart disease.

Total success rate: 76%Of 8745 patients:

27.3% required 1 procedure52.0% asymptomatic without drugs23.9% asymptomatic with an AAD within <1

yr

Outcome may vary between centres

Worldwide Survey on Efficacy and Safety of Catheter Ablation for AFib

Cappato R, et al. Circulation (2005) 111: 1100

RF ablation vs AAD as first-line treatment for AFib

• Wazni OM et al. JAMA (2005) 293: 2634-2640

Catheter ablation in drug-refractory AFib• Stabile G et al. Eur Heart J (2006) 27: 216-221

Circumferential PV ablation for chronic AFib• Oral H et al. N Engl J Med (2006) 354: 934-941

Randomised Clinical Trials of Catheter

Ablation

Randomized Controlled Trial of Amiodarone + Cardioversion + Catheter Ablation

Oral H, et al. N Engl J Med (2006) 354: 9

Sin

us r

hyth

m (

%)

120

20

60

100

80

40

Months

1110987654321

Circumferentialpulmonary-vein ablationControl

Amiodarone & cardioversion (n=69) vs. amiodarone & cardioversion plus PV ablation (n=77)

Transient ischaemic attack 4 0.4 0 - 3

Permanent stroke 1 0.1 0 - 1

Severe PV stenosis(>70%, symptomatic) 3 0.3 0 - 3

Moderate PV stenosis(40-70%, asymptomatic) 13 1.3 0 - 5

Tamponade / perforation 5 0.5 0 - 3

Severe vascular access complication 3 0.3 0 - 4

Events(n)

Range in studies(%)

Rate(%)Complication

Complications Reported by Leading Centres

Major complications with pulmonary vein ablationin 1039 patients (6 series)

Verma A & Natale A Circulation (2005) 112: 1214

118 patients with symptomatic,drug-refractory AFib

32 weeks

1.52 ± 0.71 ablation procedures

Catheter ablationPharmacological treatment

Catheter Ablation May Be More Cost-effective than Pharmacological Therapy

Weerasooriya R, et al. Pacing Clin Electrophysiol (2003) 26: 292

€4715 followed by €445/year€1590/year

After 5 years, the cost of RF ablation was below that of medical management and further diverged thereafter

Clinical visits per year 7.4 (2.5) 1.1 (0.6)

Emergency room visits per year 1.7 (0.9) 0.03 (0.17)

Hospitalization days per year 1.6 (0.8) 0 (0)

Healthcare costs per year $1920 (889) $87 (68)

No ablation Catheter ablation

Differences in Hospital Visits and Costs with and without Catheter Ablation

Goldberg A, et al. J Interv Card Electrophysiol (2003) 8: 59

Although the initial cost of ablation is high, after ablation, utilization of healthcare resources is significantly reduced

Current ACC/AHA/ESC Guidelines

RecurrentParoxysmal AF

Minimal orno symptoms

Disabling symptomsin AF

Anticoagulation and rate control as needed

Anticoagulation and rate control as needed

No drug for preventionof AF AAD therapy

AF ablation if AADtreatment fails

ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation

Life style modification and AFLEGACY and ARREST-AF trials

LEGACY 2015

Methods

Results—AF freedom in different groups

Results

ARREST-AF 2014

ARREST-AF

Results

ARREST-AF