Katheterablatie van atriumfibrilleren

Waar staan we?

Lukas Dekker

Ik sta meestal hier

Katheterablatie van atriumfibrilleren

Waar staan we?= Outcome

Lukas Dekker

Agenda

• What are the relevant endpoints?• Outcome in paroxysmal, persistent and

permanent AFib.• Potential determinants of outcome.• Longterm follow up.• Outcome in structural heart disease.• Outcome in various age groups.

Potential endpoints

• Symptoms. Asymptomatic episodes occur, and probably more often after PVI.

• ECG monitoring. The more, the lower the success.• Long term endpoints. Often only 1 yr follow up.• With or without AAD. Often put together.• ‘Hard endpoints’. Reduction of stroke and mortality?• Health economics. PVI seems cost-effective after 4 y.

What are relevant endpoints?

Symptoms will fool you

Quirino et al. PACE. 2009;32:91-98

What are relevant endpoints?

Method of monitoringWhat are relevant endpoints?

1- or 7-day Holter at 0,3,6,12 m. Kottkamp et al. JACC. 2004

Outcome: the surgeon leads the way

95% SRQoL

MAZE for lone AFibJessurun, Circulation 2000;101:1559-67

Lönnerholm, Circulation 2000;101:2607-11

Outcome in paroxysmal, persistent and permanent AFib

Paroxysmal AFibOutcome in paroxysmal, persistent and permanent AFib

The A4 study. 1,8 PVI per patient. 24 h Holter at 3,6, 12 m. Endpoint: >3’ AF or symptoms

Jais et al. Circulation.2008;118:2498-2505

Long lasting, persistent AFib

Stepwise approach for persistent AFibHocini et al. JACC. 2010;55:1007-1016

Outcome in paroxysmal, persistent and permanent AFib

LA termination. 12 y AFib

RA termination.23 y AFib

No termination.35 y AFib

Permanent AFibOutcome in paroxysmal, persistent and permanent AFib

Elayi et al. Heart Rhythm. 2008.5:1658-1664

CPVA= circumferential PV-ablationPVAI = PV-isolationPVAI = PV-isolation + CFAE-ablation

Permanent AFibOutcome in paroxysmal, persistent and permanent AFib

Ultra-structural remodelingOutcome in paroxysmal, persistent and permanent AFib

Fisher JD, et al. PACE 2006;29:523-537

Outcome depends on input Outcome in paroxysmal, persistent and permanent AFib

Haïssaguerre’s ApproachPotential determinants of outcome

Haissaguerre et al. NEJM. 1998;339:659-666

Circumferential ablationPotential determinants of outcome

Segmental or Circumferential ?

Karch et al.Circulation 2005 Oral et al. Circulation 2003

Potential determinants of outcome

Size mattersPotential determinants of outcome

Cappato et al. Circulation.2005;111:1100-1105

Size really mattersPotential determinants of outcome

Cappato et al. Circulation.2005;111:1100-1105

Atrial size matters too

N=88Parikh et al. PACE. 2010;33:523-540

Some patients probably surrender more easilyLong term follow up

The future remains full of questions Long term follow up

FU 38 m. after PVI for persistent AFibPratola et al. Circulation. 2008;117:136-143

Do not forget about your patient!Long term follow up

AF-free 1 yr after PVI without AADShah et al. JCE. 2008;19:661-667

Hypertension!Anticoagulation?

PVI in HCMOutcome in structural heart disease

=on/off AAD

=off AAD

Bunch et al. JCE. 2008

PVI in heart failureOutcome in structural heart disease

Change in LVEF (n=58)

SR in 78%Hsu et al. NEJM. 2004; 351:2373-2383

PVI in “heart failure”Outcome in structural heart disease

Hsu et al. NEJM. 2004; 351:2373-2383

PVI as first line therapy in the young?Outcome in various age groups

0% complicationsLeong-Sit et al. Circ A&E.2010;3:452-457

N=232 N=438 N=570 N=308

AFib is age dependentOutcome in various age groups

PULMONARY VEIN ABLATION VERSUS AMIODARONE IN THE ELDERLY

PAVANE

Outcome in various age groups

Conclusions

• PVI has developed into a very efficacious treatment.

• PVI may be on its way to become first line therapy in selected patients, such as the young.

• More data on hard endpoints and longterm follow-up are needed.