Atrial fibrillation April 2010 : 1,980,000 March 2011: 2,550,000 hits November 2014: 9,500,000 hits

 AF is a common cardiac rhythm disturbance and increases in prevalence with advancing age. Approximately 1% of patients with AF are <60 years of age, whereas up to 12% of patients are 75 to 84 years of age.  More than one third of patients with AF are ≥80 years of age.

 AF is associated with a 5- fold increased risk of stroke and stroke risk increases with age. AF-related stroke is likely to be more severe than non–AF-related stroke  AF is also associated with a 3-fold risk of HF and 2- fold increased risk of both dementia and mortality, and AF is estimated to contribute to > 99,000 death/year.

Diagnosed heart failure29.2% Hypertension49.3% Diabetes mellitus17.1% Previous coronary heart disease34.6% Characteristic(n=17,974) Baseline characteristics of 17,974 adults with diagnosed AFib, July 1, 1996-December 31, 1997 Go AS, et al. JAMA (2001) 285: 2370 ATRIA study

› AFib is responsible for a 5-fold increase in the risk of ischaemic stroke Wolf PA, et al. Stroke (1991) 22: 983 Go AS, et al. JAMA (2001) 285: 2370 Friberg J, et al. Am J Cardiol (2004) 94: Cumulative stroke incidence (%) Women AFib+ Women AFib- Men AFib+ Men AFib- Years of follow-up

Framingham Heart Study, n=5209 Benjamin EJ, et al. Circulation (1998) 98: 946 Follow-up (y) Mortality during follow-up (%) Men AFib+ Women AFib+ Men AFib- Women AFib-

AF is a supraventricular tachyarrhythmia with uncoordinated atrial activation and consequently ineffective atrial contraction. Electrocardiogram (ECG) characteristics include: 1) irregular R-R intervals (when atrioventricular conduction is present), 2) absence of distinct repeating P waves, and 3) irregular atrial activity.

Management of Arrhythmia Rate Control Rate Control Rhythm Control Rhythm Control AF Detected Detection and Treatment of Precipitating Causes No antithrombotic therapy may be appropriate in selected young patients with no stroke risk factors ASA OAC ASA OAC Assessment of Thromboembolic Risk (CHADS 2 )

 Identify and treat underlying structural heart disease and other predisposing conditions  Relieve symptoms  Improve functional capacity/quality of life  Reduce morbidity/mortality associated with AF/AFL

 Prevent tachycardia-induced cardiomyopathy  Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL  Prevent stroke or systemic thromboembolism

3/5/2014 Haïssaguerre, M, Jaïs, P, Shah, DC, et al.N Engl J Med (1998) 339: 659  Pivotal study identifying the pulmonary veins as a major source of ectopic electrical activity  Radiofrequency ablation of ectopic foci was associated with a 62% success rate (absence of recurrence at 8  6m follow-up) Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins

Maze reproductionSchwarz 1994 Right atrial linear lesionsHaïssaguerre 1994 Right and left atrial linear lesionsHaïssaguerre 1996 PV foci ablationJaïs / Haïssaguerre 1997/8 Ostial PV isolationHaïssaguerre 2000 Circumferential PV ablationPappone 2000 Ablation of non-PV fociLin 2003 Antral PV ablationMaroucche / Natale 2004 Double Lasso techniqueOuyang / Kuck 2004 CFAE sites ablationNademanee 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

Class I 1) AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired. (Level of Evidence: A) 2) Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C)

Class IIa 1) AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. (Level of Evidence: A) 2) In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of AADs after weighing risks and outcomes of drug and ablation therapy. (Level of Evidence: B)

Class IIb 1) AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III AADs, when a rhythm control strategy is desired. (Level of Evidence: B) 2) AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C)

Class III: Harm 1) AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C) 2) AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)

3/5/ HRS/EHRA/ECASE xpe r t consenss statement on catheter and surgical ablation of AF

First AF ablation in Iran was performed in /5/2014

Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation:

LASSO ® Ablation catheter LAO RAO

 Total success rate: 76%  Of 8745 patients: › 27.3% required 1 procedure › 52.0% asymptomatic without drugs › 23.9% asymptomatic with an AAD within <1 yr  Outcome may vary between centres Cappato R, et al. Circulation (2005) 111: 1100

Pappone C, et al. J Am Coll Cardiol (2003) 42: 185 Days of follow-up Ablation Group Medical Group One-sample log-rank test Obs=36, Exp=31, Z=0.597, p= One-sample log-rank test Obs=79, Exp=341, Z=7.07, p<0.001 Survival probability (%) Expected Observed 589 ablated patients compared with 582 on AADs

118 patients with symptomatic, drug-refractory AFib 32 weeks 1.52 ± 0.71 ablation procedures Catheter ablationPharmacological treatment 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

The decision whether to pursue catheter ablation depends on a large number of variables, including the type of AF (paroxysmal versus persistent verses longstanding persistent), degree of symptoms, presence of SHD, candidacy for alternative options such as rate control or AAD therapy, likelihood of complications, and patient preference.

 Two RCTs compared radiofrequency catheter ablation with antiarrhythmic drug therapy as a first-line rhythm control treatment. The RAAFT (Radiofrequency Ablation Versus Antiarrhythmic Drug for Atrial Fibrillation Treatment) II trial compared the efficacy of AF catheter ablation with that of AAD therapy as first- line therapy for rhythm control in 127 patients (88% paroxysmal AF) with a higher 1-year freedom from AF (45% versus 28%; p=0.02).

 The MANTRA-PAF (Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation) trial compared AF catheter ablation with AAD therapy as first-line therapy in 294 patients.  At the 24-month follow-up, more patients in the ablation group were free from any AF or symptomatic AF and quality of life was significantly better.

On the basis of these data, radiofrequency catheter ablation may be considered as first-line therapy in select patients prior to a trial of antiarrhythmic drug therapy when a rhythm control strategy is desired.

Recurrences of AF after catheter ablation are common during the first 3 months and do not preclude long-term success, although they are associated with an increased risk of procedural failure and rehospitalization. Therefore, when AF occurs early after catheter ablation, a pharmacologic rhythm control approach rather than early repeat ablation should be considered

Patients who have had AF catheter ablation and develop persistent AF within the 3 months following ablation may require cardioversion. Recurrent AF after 3 months is usually an indication of recovery of pulmonary vein conduction and may respond to repeat ablation or initiation of an antiarrhythmic drug.

 831 patients.  At 1 year, 633 (76%) were free of arrhythmia  17 (2%) had recurrence managed with antiarrhythmic drugs  161 (19%) had recurrence managed with a second ablation  20 (2%) had recurrence managed with rate control. Hussein AA, Saliba WI, Martin DO, et al. Natural history and long-term outcomes of ablated atrial fibrillation. Circ Arrhythm Electrophysiol 2011;4:271-8.

 Because of the well-established risk of periprocedure stroke or TIA associated with AF catheter ablation, there is consensus that anticoagulation is indicated to prevent thromboembolism around the time of RFCA regardless of the patient’s baseline thromboembolic risk

 Continuation of anticoagulation >2 months following AF catheter ablation, if the procedure is perceived successful, should be based on consideration of the patient's thromboembolic risk profile, bleeding risk, and patient choice.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database from 2005 to 2010 recorded 91,801 AF surgical ablations, of which 4,893 (5.3%) were stand-alone procedures. The FAST (Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment) trial compared the outcomes of catheter ablation and surgical ablation in a randomized study design.

Patients either had left atrial dilation and hypertension (42 patients, 33%) or failed prior catheter ablation (82 patients, 67%). Freedom from atrial arrhythmias was greater after surgical ablation compared with catheter ablation, but the complication rate after surgical ablation was higher.

Type of Complications Rate, %  Death 0.15  Tamponade 1.31  Pneumo/ Hemothorax 0.11  Sepsis, abscesses or endocarditis 0.01  Permanent diaphragmatic paralysis 0.17  Femoral pseudoaneurysm / A-V fistula 0.93/ 0.54  Valve damage/requiring Surgery 0.07  Atrium-esophageal fistula 0.02  Stroke / TIA 0.23 / 0.71  Pulmonary vein stenoses requiring intervention 0.29  Total Pappone et al, Circulation

Recent published European registry (2013): AF ablation complication : % ≈5%

 Rate control as preferred therapy › Age > 65, less symptomatic, hypertension › Recurrent afib › Previous antiarrhythmic drug failure › Unlikely to maintain sinus rhythm (enlarged LA)

 Rhythm control as preferred therapy › ? First episode afib › Reversible cause (alcohol) › Symptomatic patient despite rate control › Patient unable to take anticoagulant (falls, bleeding, noncompliance) › CHF precipitated or worsened by afib › ? Young afib patient (to avoid chronic electrical and anatomic remodeling that occurs with afib)

 AF is the most frequent sustained cardiac arrhyhthmia.  2014 guideline assigned AF ablation as first ( Class IIa) and second line (Class I) rhythm control strategy.  Many studies shown priority of AF ablation over AAD therapy( RAAFT, STOP-AF, CABANA)  AF ablation needs special training and facilities.

 Patients not offered Catheter ablation if › Very long standing Persistent AF (>3 years) › Very large LA (>5.5 cm) › Morbid Obesity (BMI >40), Sleep Apnea › Significant RA dilatation (>LA)  Patients not offered first redo at least for 6 months  Not offered Second redo if still in PsAF

Feel BetterFeel SameFeel Worse Live Longer Live Same Live Shorter Anticoagulant Rate Control Ablation Antiarrhythmicdrugs