Ablation ou traitement

pharmacologique pour la FA:

quelle stratégie a suivre ?

Luc Jordaens

Nouvelles frontières pour la prise en chargede la fibrillation auriculaire

Brussels 29-11-2014

Usual care: Current AF management

ESC guidelines for the management of AF

Camm AJ, Kirchhof P, et al. European Heart Journal 31: 2369-2429. (2010)

Maintenance of sinus rhythmin atrial fibrillation

received a bad reputation in the early years 2000

AFFIRM

NEJM 2002;347:1825

• 4060 patients

• No survival benefit (23.8% vs 21.3%)

• 23 % Prior HF

Atriale fibrillatie en hartfalen (HF):overleving (cardiale sterfte) i.f.v. behandeling

Naar Flaker, SPAF studie 1992

0 90 180 270 360 450 540 630 720

Tijd in SPAF (dagen)

0

20

40

60

80

100%

HF, wel AAD

HF, geen AAD

Class Ic anti-arrhythmics

AF + RBBB + LBBB

VT ?

Sinus

RACE : Sub-study HF

Hagens et al. Am Heart J 2005;149:1106

If sinus rhythm is maintained,

prognosis may

improve (less CV

death, HF

hospitalizations

and bleeding)

DIAMOND : sinus rhythm and mortality

Pedersen et al. Circulation 2001;104:292

• 506 pts with LV dysfunction

• Randomized to Dofetilide or Placebo

• No effect on mortality

• Effect of SR on mortality RR 0.44 (0.30-0.64)

Survival according to Rx

Survival according to rhythm

Atrial fibrillation: rate or rhythm control ?

Rate control can be acceptable

Rhythm control has some

advantages , when wisely used

SINUS RHYTHM IS BETTER !

Catheter / surgical ablationis aimed to

achieve sinus rhythm

First diagnosed episode of AF

Persistent

(> 7 days or requires CV)

Long standing

Persistent (> 1 year)

Permanent

(accepted)

Paroxysmal

(usually ≤ 48 h)

Silent AF

12

AF Duration

AF is a Progressive Disease

Paroxysmal

Trigger dependent(Initiation)

Permanent

Substrate dependent

(Maintenance)

Rela

tive

Imp

ort

an

ce

Khan IA. Int J Card. 2003;87:301-302

PAROXYSMAL PERSISTENT

maintain sinusrhythm !

maintain sinusrhythm !

cardioversionDRUGS

DRUGS

ABLATION

ANTIARRHYTHMIC DRUGS AND AF

Sopher and Camm, 1996

?

ANTIARRHYTHMIC DRUGS AND AF Rhythm control

ANTIARRHYTHMIC DRUGS AND AF Rhythm control

2 late +

INCLUSIONN = 39

DIGOXIN9 / 19

PLACEBO8 / 20

Digoxin in high IV dose for PAF

Jordaens et al, 1997

HEART RATE ACCORDING TO TREATMENT GROUP

0 10 20 300

50

100

150

200beats / min

18

17

16

17

min

: p < 0.02*

*

NS

< 0.002

CONVERTERS AND TREATMENT

0 10 20 300

50

100

150

200beats / min

< 0.02

NS

7

96

8

Placebo

Digoxin

New class IIIdrugs

Vos et al, 1998

Duytschaever et al, PACE 1998

Roy et al, 2000

Patients without

recurrence (%)

Prophylactic antiarrhythmic therapy

in ’’ paroxysmal” atrial fibrillation

Torp-Pedersen et al, 2000

Antiarrhythmic therapy

for paroxysmal atrial fibrillation in CHF

Meta analysis of drugs: mortality

11 new studies comprising 20.771 patients.

Compared with controls, class IA drugs quinidineand disopyramide (OR 2.39, 95% confidenceinterval (95%CI) 1.03 to 5.59, number needed toharm (NNH) 109, 95%CI 34 to 4985) and sotalol (OR 2.47, 95%CI 1.2 to 5.05, NNH 166, 95%CI 61 to1159) were associated with increased all-causemortality. Other antiarrhythmics did not seem tomodify mortality.

Cochrane review, 2012

• Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.70, number needed to treat (NNT) 3 to 16).

• Beta-blockers (metoprolol) also reducedsignificantly AF recurrence (OR 0.62, 95% CI 0.44 to 0.88, NNT 9).

Meta analysis of drugs: efficacy

Cochrane review, 2012

• All analysed drugs increased withdrawals dueto adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia.

• Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established.

Meta analysis of drugs: adverse effects

Cochrane review, 2012

ESC guidelines 2012

Drugs or ablation ?

Wilber et al, 2012

Morillo et al, 2014

Paroxysmal AF vs drugs – RAAFT 2

KCE, 2012

KCE, 2012

Catheter ablation for AF

• A total of 32 RCTs (3.560 patients) were included. RCTs were small in size and of poor quality.

• CA compared with medical therapies: 7 RCTsindicated that CA was better in inhibiting AF recurrence [RR 0.27; 95% CI 0.18, 0.41)] (withsignificant heterogeneity).

• There was limited evidence to suggest that sinus rhythm was restored during CA (RR 0.28, 95% CI 0.20-0.40), and at the end of follow-up (RR 1.87, 95% CI 1.31-2.67; I2=83%).

Cochrane library, Chen et al, 2012

Catheter ablation for AF

• There were no differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65), fatal and non-fatalembolic complication (RR 1.01, 95% CI 0.18 to 5.68) or death from thrombo-embolic events (RR 3.04, 95% CI 0.13 to 73.43).

Cochrane library, Chen et al, 2012:

Catheter ablation for AF

Comparisons of different CAs; 25 RCTscompared CA of various kinds.

Circumferential pulmonary vein ablation was better than segmental pulmonary veinablation in improving symptoms of AF (p<=0.01) and in reducing the recurrence of AF (p<0.01).

There is limited evidence to suggest whichablation method was the best.

Cochrane library, Chen et al, 2012:

ESC guidelines 2012: paroxysmal AF

Incidence of new ischemic events (ACT >300)

No clinical events

2/27 (7.4%) 1/23 (4.3%) 9/24 (37.5%)

P=0.003

Herrera C et al. J Am Coll Cardiol 2011;58:681-88

Antral isolation

Ostial isolation

before & after

ANTRAL ABLATION

Van Belle et al, 2008

Early and late recurrence : event-free rates after one procedure with blanking

AFICE

Months

24120

Act

uari

al e

vent

-fre

e r

ate (

%)

100

0

80

60

40

20

N atrisk 1137

135 1563

73%

AF (only after

3 months)

N = 141

(any AF)

135Van Belle et al, Europace 2008

Early and late recurrence : event-free rates after one procedure with blanking

AFICE

Months

24120

Act

uari

al e

vent

-fre

e r

ate (

%)

0

40

20

100

80

6073%

N = 141

(any AF)

Van Belle et al, Europace 2008

This will be betterwith the new balloon

AF

ICE

Months

24120

Act

uar

ial e

ven

t-fr

ee r

ate

(%)

100

0

80

60

40

20

All AF

N atrisk 1137

135 1563

73%

Early and late recurrence : event-free rates after one procedure with and without blanking

AF (only after

3 months)

N = 141

(any AF)

135Van Belle et al, Europace 2008

• No PV narrowing (30% criterion; repeated MRI)

• Phrenic Nerve Palsy: 26/346 patients, usual with the small balloon

• No fistula, death, stroke…

Cryoablation with the ICE balloon:results of a multicentre study

Neumann et al, JACC 2008

Cryoballoon efficacy – Meta analysis

Andrade JG, et al. Heart Rhythm 2011

Comparable efficacy to conventional RF

1 Andrade JG, et al. Heart Rhythm. Published online March 30, 2011.4 Calkins H, et al. Circ Arrhythm Electrophysiol. August 2009;2(4):349-361.

Better than conventional RF ?

Onset VTAF

Wat zijn onze resultaten ?

blijven de zelfde na 550 procedures

( > 100 in BHC)

Geen CVA / TIA

Geen PV stenose

Geen overlijden

Persistent Atrial fibrillation: suitable for catheter ablation?

Paroxysmal Persistent Permanent

*

0

10

20

30

40

50

60

70

80

Mild Moderate Extensive

Paroxysmal AF

Persistent AF

Marrouche et al, JAMA 2014

KCE, 2012

Survival curves for the primary endpoint in persistent AF

Mont L et al. Eur Heart J 2014;35:501-507

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 3 6 9 12 15 18

Arh

hyth

mia

fre

e s

urv

iva

l

Follow up (months)

346 250 38120128215

n pts

paroxysmal = 293

persistent = 53

Event Free Probability in Pts Without AAD After 3 Month

Neumann et al

Only 41 with FU > 3 months

Neumann et al, JACC 2008

METACSAExpected to recruit jan. 2015

Persistent “Light” Atrial fibrillation:

suitable for catheter ablation ?

Exclusion of valvular pathology

METACSA (PROSPECTIVE STUDY OF MEDICAL

THERAPY AGAINST CRYOBALLOON ABLATION IN PATIENTS WITH SYMPTOMATIC RECENT ONSET

PERSISTENT ATRIAL FIBRILLATION)Expected to recruit jan. 2015

Persistent “Light” Atrial fibrillation:

suitable for catheterablation ?

Exclusion of valvularpathology

Normal atrial size

More info or a candidate ?

luc@jordaens.be

BHCSt LucULgUZ GentR’dam

1. Catheter ablation seems to be betterthan drug therapy for paroxysmal AF (widecircumferential ablation)

2. Persistent atrial fibrillation without valvular pathology and normal anatomyseems to be treatable with catheterablation

3. There are not enough goodantiarrhythmic drugs on the market in Belgium

PAROXYSMAL PERSISTENT

maintain sinusrhythm !

maintain sinusrhythm !

cardioversionDRUGS

DRUGS

ABLATION