what’s cooking in my specialty? - ogden surgical...am j med 2014 127 e15-e16 most common...

5/9/2017

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What’s new in my specialty? Jon Melman, MD

Heart Rhythm Specialists

McKay-Dee Hospital

…some would say…

…some would say… my specialty…

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• First pacemaker 1958



• First ICD 1980



• First ICD 1980

• First ABIM boards 1992

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• First ICD 1980

• First ABIM boards 1992

• First RF ablation 1994

Electrophyisology: Continues to expand in scope and therapies

• Study of cardiac arrhythmias

• Medical management of arrhythmias


• Medical management

• Pacemaker placement


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• ICD implantation






• Implantable loop recorders






• Catheter ablation


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• Catheter ablation

• Hereditary and genetic arrhythmias• LQTS, HCM, ARVC, myotonic dystrophy, CPVT, etc

Catheter Ablation in Electrophysiology: Pre-RF

• First performed using DC shocks for AV node ablation (1981)

RF Catheter ablation in electrophysiology

• First RF performed 1994• Localized application of RF energy

• Minimal surrounding tissue damage

• Highly effective for ablation

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RF ablation: a Controlled form of electrosurgery

Fluoroscopy: Traditional imaging modality

Tricuspid annulus

Ablation catheter

Coronary sinus

Lateral RA• X-ray based imaging

• Useful for imaging heart in real-time

• Can be difficult to precisely keep track ofcatheter location during prolonged/complex ablations

Electroanatomic mapping

• Localizes the catheter in three dimensions

• Allows marked reduction in X-ray use

• Fluoroscopy-free ablations now being performed

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Using a mapping system to track catheters and make a map of the heart



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Propagation map showing atrial flutter

Cavotricuspid isthmus

…ablating along the line…..

How effective is RF ablation?

Arrhythmia Acute Success Rates Complication Rates

AVNRT 95-99% 2-5%

WPW/AVRT 90%-98.5% 2-3%

Atrial flutter 95%-100% 3.2%

Atrial Tachycardia 90%-98.5%

PVCs/Idiopathic VT ~50%-95% 2-5%

Atrial fibrillation 40-80%

Ischemic VT 30-90%

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Importance of atrial fibrillation

Patient symptoms:Irregularity in rhythm

Loss of atrial “kick” : ~30% of LV filling at baseline, more with structural heart diseaseTachycardia and tachycardia-mediated cardiomyopathy

Some patients completely asymptomatic

Stroke risk:15% of all strokes in US

36% of strokes in individuals above age 8020% of cryptogenic stroke

Am J Med 2014 127 e15-e16

Most common arrhythmia seen in clinical practice

What is atrial fibrillation?Chaotic “fibrillatory” activity in the atrium

Irregularly irregular ventricular rhythm

Unpredictable/difficult to control rate

What is atrial fibrillation?

Irregularly Irregular

Disorganized atrial activity

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Treatment of atrial fibrillation: Rhythm or rate control?

• Rate control: control the rate with an AV nodal blocker • i.e. beta blocker, calcium channel blocker, digoxin

• Rhythm control: Antiarrhythmic drugs, catheter ablation• Class IA, IC, III antiarrhythmics• Catheter ablation

Treatment of atrial fibrillation: Rhythm or rate control?

AFFIRM trial: are rate and rhythm control equal?

• 4060 patients• Average age 70 (pts all had to be over 65 y/o with at least one other risk factor)• Randomized to rate control (digoxin, beta and/or CCB) or:

• Rhythm control (30% on amiodarone, 31% on sotalol• 15% crossed over to rhythm control due to symptoms, 38% crossed to rate control due to failure of rhythm control

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• Established the standard of care as a choice of rate versus rhythm control

But….

Are these results applicable to other AF patient populations? Do the results apply to all AF patients uniformly?

Follow up: on-treatment analysis

Cox proportional hazard model applied to AFFIRM data

Increased mortality if:

Unable to maintain sinus rhythm

On an antiarrhythmic drug

NO patients under 60 with LOW stroke riskEffects of AF maintenance over decades of life not well understood

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323 patients with symptomatic AF (40% persistent)72% arrhythmia free off AADs at 2 years

15% controlled AF on antiarrhythmic drugs

13% recurred

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Patients with EF <35%, persistent AF randomized to rate control vs catheter ablation

Primary outcome : changein VO2 max

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Patients with EF 40% or less, NYHA Class II-III and symptomatic, drug-resistant AF

Randomized to PVI or up-front AVN ablation with BiV pacing

At 6 months: Improved 6-minute walk distance

Higher EF (35% vs 28%)

How do we “ablate” atrial fibrillation?

• No single circuit with an isthmus, location or pathway that terminates atrial fibrillation

• We target the signals that trigger episodes of atrial fibillation

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Pulmonary Vein Isolation

• Durable isolation is the cornerstone of AF ablation

• Can be performed via RF ablation (point-by-point ablation around the pulmonary veins)

• Cryoballoon: • Balloon is used to occlude PV ostium

• Freezing is used to isolate the entire vein in one step

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Most recent trial of AF ablation

127 patients with symptomatic paroxysmal AF, randomized to PVI vs AAD

Recurrences monitored by ECG, holter, and/or transtelephonic transmission

Excluded patients over 75, EF<40%, LA>5.5cm

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Cryoballoon Ablation at McKay-Dee Hospital

Catheter Ablation For Paroxysmal AFPulmonary Vein Isolation with irrigated focal RF ablation catheter

53

RF Ablation Catheter

Ablation Lesion

Ablation Lesion

Catheter Ablation For Paroxysmal AFPulmonary Vein Isolation with Arctic Front Advance cryoballoon catheter

54

RF Ablation Catheter

Cryoballoon Ablation Catheter

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Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

Secondary outcomes of FIRE and ICE

Outcomes of FIRE and ICE

Outcome Cryoballoon, N=374, n (%)

RF, N=376, n (%)

Absolute difference (%)

P Prespecified

Rehospitalization for CV cause

89 (23.8) 135 (35.9) 12.1 <0.01 Yes

Rehospitalization for any cause

122 (32.6) 156 (41.5) 8.9 <0.01 No

Cardioversion 12 (3.2) 24 (6.4) 3.2 0.04 No

Repeat ablation 44 (11.8) 70 (17.6) 5.8 0.03 Yes

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RF ablation lesion set

Conclusions

• The EP field is rapidly evolving and expanding with new devices, RF catheter ablation techniques and mapping systems

• Atrial fibrillation ablation is improving and providing previously symptomatic patients with improved quality of life and better symptom control

• Cryoballoon ablation at McKay-Dee provides shorter procedure times, decreased incidence of recurrent arrhythmias and rehospitalization

• The EP service at McKay-Dee is always available for any patient need, inpatient or outpatient and is easily reached on the RAFT hotline

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Thank you

Paroxysmal Atrial FibrillationAF lasting < 7 days

Not requiring cardioversion for termination OR antiarrhthmic drugs to control

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• 294 patients with PAF randomized to AAD vs RF PVI,

• 58 pts underwent a repeat procedure

• AF recurrence detected by 7 day holter

• Primary outcome was burden of Afib on Holter• Secondary outcome: freedom from afib and freedom from symptomatic Afib

• At 24 months:• 85% of ablation patients were free of atrial fibrillation, 93% free from symptomatic AF

(p=0.01 over drug therapy)• Despite a 36% crossover from drug to ablation therapy

N Engl J Med 2012; 367:1587-1595

• 146 Patients with symptomatic persistent AF, randomized2:1 catheter vs AAD• Excluded longstanding persistent AF, JCM, EF<30, LA>50mm, prior ablation

what’s cooking in my specialty? - ogden surgical...am j med 2014 127 e15-e16 most common...

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