Transcript Titel

Long-term FU of Catheter Ablation of
Paroxysmal Atrial Fibrillation
Feifan Ouyang
AK St. Georg
Hamburg
Catheter ablation of AF
EHS • Euro Heart Survey • Admission/Consultation Information
First detected
(n = 978)
Paroxysmal
(n = 1517)
Persistent
(n = 1167)
Permanent or
long-standing
AF
(n = 1541)
AF only
446 (46 %)
709 (47 %)
577 (50 %)
361 (24 %)
Never AF
symptoms
150 (16 %)
86 (6 %)
119 (10 %)
293 (21 %)
Heart failure
NYHA class
III/IV
162 (17 %)
113 (8 %)
170 (15 %)
382 (25 %)
LA diameter
(mm)
43 (± 8)
43 (± 7)
46 (± 8)
51 (± 17)
Nieuwlaat et al. EHJ 2005;26:2422–2434
PAF —> CAF
FollowPatients
up
n
(y)
PAF —> CAF
n Pts
%
65/757
(187/757)
8.6
(24.7)
Kerr 2005
757
1
(5)
Ruigómez 2005
418
2
70/418
17
Abe 1997
122
2
13/122
11
Sakamoto
137
1
30/137
22
Kato 2004
171
14
132/171
77.2
De Voss 2010
1219
1
178/1219
15
De Voss et al. JACC 2010
AF Ablation Strategies
Heart Rhythm. 2007 Jun;4(6):816-61.
HRS/EHRA/ECAS Consensus Statement
Heart Rhythm. 2007 Jun;4(6):816-61.
Calkins H. et al. Circulation 2009
Clinical trial
Authors
Total AAD before FU
CA
AAD
Wanzi
Pappone
70
198
87%
93%
23%
35%
Stabile
137
no use
1
long PAF
1-Y
failed AAD
failed
1-Y
Jais
112
failed (≥1)
89%* 23%
1Y
Pappone C et al. JACC 2006, 48:2340-47
Stabile G et al. Eur Heart J 2006; 27:216-221
Wanzi OM et al. JAMA 2005; 293:2634-2640
Jais P et al. Circulation 2008;118:
65.9% 8.7%
Personal communication
- 96% from Pappone’s laboratory
- 48% from USA’s laboratory
COMPLICATIONS - World Wide Survey
Cappato et al. Circulation 2005; 111; 1100-1105, JACC 2009;53:1798
Complication Risk Factors
13
R. R. Tilz et al, Clin. Res. Cardiol 99, Suppl 1, 4.2010
953 patients from Cleveland Clinic (Cleveland, OH, USA) from December 2000 to June 2004;
102 patients from Sutter Pacific Heart Center (San Francisco, CA, USA) from June 2001 to December 2002;
89 patients from Southlake Regional Health Center (Newmarket, Ontario, Canada) from March 2004 to March 2006;
260 patients from Umberto I Hospital (Mestre-Venice, Italy) from September 2002 to June 2006
Bhargava et al. HR 2010
Clinical outcome during long-term FU using ICE
Bhargava et al. HR 2010
PV isolation with Carto and double Lasso
Pts characteristics
•
•
•
•
Circumferential PVI was performed using a
combination of 3-D and double Lasso technique
in 171pts with recurrent PAF in 2003-2004
Recurrent PAf was refractory to Antiarrhythmic
drugs
FU was difficult in 10 patients from other country
Irrigated RF energy was used with 30-40 Watts
Baseline Characteristics
CHADS Score
In 161 pts with PAF before 1st ablation procedure
CHADS II Score
0
1
No of pts
48 (29.8 %)
86 (53.4 %)
2
3
4
19 (11.8 %)
7 (4.3 %)
0
5
1 (0.6 %)
Circumferential PVI with Carto and double Lasso
Procedure endpoints during 1st procedure
•
•
•
Absence of all PV spikes documented with the 2
lasso catheters within the ipsilateral superior
and inferior PVs at least 30 minutes after
isolation
no recurrence of the PV spikes within all PVs
following intravenous administration of 9 to 12
mg of adenosine during SR or CS pacing.
Block of cavotricuspid isthmus if the patients
had common-type AFL
Circumferential PVI
LSPV
LIPV
His
Map
LSPV
LIPV
Ouyang F et al. (Circulation 2004;110:2090–2096)
CS
LAA
PV isolation with Carto and double Lasso
Procedure endpoint of 2nd and 3rd ablation procedure
•
•
In patients without recovered PV conduction
–
Termination of AT if AT was found during procedure
–
Ablation of CFAE if AF
In patients with recovered PV conduction
–
•
Closing the conduction gap during SR or PVT
In Patients with Macro-AT
–
Termination of Macro-AT using 3-D mapping
–
Closing the conduction gap in case of recovered PV
conduction
Circumferential PVI with Carto and double Lasso
Follow-up
•
•
•
•
•
No blanking period in all pts
All patients on the previously ineffective antiarrhythmic drugs
for one-3 month after the ablation.
ECG and 24-hrs Holter recording were performed one day
after ablation and repeated after 1, 3, 6, 12 months and
followed by every 6 months by the referring physician or by
the ablation center.
A telemetry ECG recorder (Philips Telemedizin, Germany) to
document symptomatic arrhythmias or to transfer an ECG
once per week if asymptomatic for 6 months in all pts
No use of 7 day-holter or reveal recording
PV isolation with Carto and double Lasso
Acute Complications in 161 pts
•
•
•
•
•
•
No cardiac tamponade
No stroke or TIA
No LA-esopgagael fistula
Pericardial effusion after ablation in 2 pts
Asymptomatic PV narrowing in 3 pt
Aspiration Pneumonia in one pt
Recurrent ATa after 1st Procedure in 86/161 Pts
F/U = 4.8 (0.9 – 5.5) years
Recurrence after 1st Procedure: Time Categories
40
40
No. of Patients
30
20
12
10
0
No. of Patients
Pts. at Risk
12
5
7
2
4
4
<1
[1,3)
[3,6)
[6,12)
40
12
5
7
12
2
4
4
161
121
109
103
95
83
81
77
[12,24) [24,36) [36,48)
>48
Months
Recurrent ATa after 2nd Procedure in 22 Pts
F/U = 4.1 (2.5 – 4.4) years
Recurrence after 2nd Procedure: Time Categories
10
No. of Patients
8
5
3
2
2
3
2
2
0
0
[6,12) [12,24) [24,36) [36,48)
>48
<1
[1,3)
[3,6)
No. of Patients
2
8
2
2
3
3
2
0
Pts. at risk
66
64
56
54
52
45
35
28
Months
Results
Sumanry
Success
• No recurrence in 126/161 pts (78.3%)
• Clinical significant improvement in 23/161 pts
(14.3%)
Median FU from last procedure 4,3 ± 1 year
Median FU from first procedure 4.7 ± 0,6 years
AF recurrence after median of 60 (rang 0 - 1754)
days
Also, clinical improvement in 13.0%
Results
Medication during Follow-up
Medication
Class I/III antiarrhythmic
drugs, n (%)
- Amiodarone, n (%)
Betablocker, n (%)
Macumar
ASS, n (%)
Plavix, n (%)
ACE Inhibitor/AT 1 blocker, n
(%)
Statin, n (%)
All pts (# 161)
Pts in SR (#128)
29 (18%)
3 (2%)
64 (40%)
22 (14%)
68 (42%)
3 (2%)
19 (15%)
2 (2%)
47 (37%)
9 (7%)
56 (44%)
3 (2%)
57 (35%)
41 (33%)
39 (24%)
29 (23%)
Recurrence of atrial tachyarrhythmias
77.7% at 5 years
45.4% at 5 years
After the 1st procedure
After the last procedure (1.5±0.6)
Ouyang et al. Resubmitted to Circulation
Results
Death during Follow-up
Tim e to death
after ablation Cause ofdeath
(m onths)
Pt #
Gender/ age
#1
Fem ale/ 80
52
Unknow n
(sudden death)
SR
#2
Male/ 55
51
Suicide
SR
#3
Fem ale/ 62
4
Pneum onia
SR
#4
Male/ 71
10
Accident
SR
Rhythm FU
Results
Stroke
Pt
#
Gender/
Age
Ev ent
Time to
ev ent
after
ablation
(months)
#1
Male/ 65
TIA
20
PAF
ASS only
H: 1
#2
Male/ 70
TIA
31
SR
ASS only
H+S: 3
#3
Male/ 83
Haemorrhagic
stroke
24
SR
Warferin (INR ?)
H+A: 2
H = primary hypertension
S = previous stroke
A = aging
Rhythm
FU
Warferin or ASS
before ev ent
CHADS
score
CA of PAF on the progression towards chronic AF
Progress into persistent AF in 161 pts
during a mean of FU of 5 years
Nr.
Gender/
age
#1
2
#3
4
SHD
LA
diameter
PAF
duration
Male/ 80
CABG
55
96
Female/
57
Female/
68
Female/
61
ICD for
SCD
49
48
No
42
84
No
39
60
Time to
progression
(days)
355 after 1st
proc.
210 after 2nd
proc.
1049 after
2nd proc.
77 after 2nd
proc.
PersistentAF duration 2-6 months; Pt #1 and #3: asymptomatic
No ablation after progression into persistent AF
Catheter ablation of atrial fibrillation
Conclusions
•
Circumferential PVI can maintain stable SR after the 1st
procedure in ≈50% patients with PAF
•
The 2nd or 3rd procedure is required to improve success the
pts with recurrent ATa after 1st procedure.
•
Catheter ablation of PAF can prevent or prolong the
progression towatds chronic AF