Contemporary Atrial Fibrillation Management Morhaf Ibrahim, MD. FHRS

Nothing to Disclose

Outline Epidemiology Signs and Symptoms Etiology Differential Diagnosis Diagnostic Tests Classification Management

Epidemiology Most frequently diagnosed arrhythmia Affects 2.3 million people in the US Affects 1/136 people in the US Incidence increases with age

Signs and Symptoms Palpitations Weakness Dizziness Reduced exercise capacity Dyspnea Asymptomatic

Etiology/Risk Factors Structural heart disease Chronic lung disease Pneumonia Hyperthyroidism Alcohol use Pulmonary embolism HTN Pericarditis Key Point MI is a very rare cause of Afib!

Differential Diagnosis Narrow Complex Tachycardias Atrial Fibrillation Atrial Flutter AVNRT AVRT Atrial tachycardia Sinus tachycardia Multifocal atrial tachycardia

Classification Paroxysmal: terminates in < 7 days Persistent: fails to terminate within 7 days Long lasting persistent: > 1 year Lone: Individuals without structural heart disease, < 60 yrs old

Diagnostic Testing: EKG

Diagnostic Testing: TTE To assess for structural heart disease LVEF Wall motion Dilation/Hypertrophy Size of right and left atrium Valvular disease Pericardial disease

Chest X-Ray Look for emphasema/COPD Cardiac borders Pneumonia

Management Rate Control Rhythm Control Anticoagulation

Rate Control Why is rate control important? Goals Long term: Cardiomyopathy Goals Rest HR < 80 bpm 24 Hour (Tele/Holter) < 100 bpm average HR < 110 in 6 minute walk RACE II trial (NEJM 2010)

Rate Control (con’t) Medications Metoprolol / Esmolol: IV or Oral Diltiazem: IV or Oral Verapamil: Oral Only Digoxin: Patients with hypotension Amiodarone: Also for rhythm control

Rhythm Control Indications Symptoms of a-fib Personal preference

Rhythm Control (con’t) Synchronized DC cardioversion Emergencies/Hemodynamic instability Greater efficacy than medications Pharmacologic cardioversion Dofetilide, flecainide, ibutilide, propaferone or amiodarone

Rate or Rhythm Control? Affirm Study (NEJM 2002): Rate versus rhythm control No difference in incidence of stroke Trend towards lower mortality in the rate control group Afib ablation

Anticoagulation and Cardioversion Afib < 48 hours: Cardioversion (CV) No indication for TEE Afib > 48 hours: Anticoagulate for 3 weeks before CV OR get TEE Anticoagulate for 1 month after CV regardless of CHADSVASC score

Anticoagulation – Long Term

Key Points MI is a rare CAUSE of a-fib Rate control must be achieved during exercise, not just at rest Not every patients needs to bridge with heparin Unstable patients should immediately be cardioverted

Atrial Fibrillation Ablation

Left Atrium Posterior Basal View R. pulmonary artery L. pulmonary artery R. superior pulmonary vein L. auricle L. superior pulmonary vein L. atrium R. inferior pulmonary vein Olshansky via Medtronic (modified) ____ Demonstrates the anatomy of the left atrium, especially of the pulmonary veins. These can be sites of origin of not only left atrial tachycardias, but also of AF. L. inferior pulmonary vein Coronary sinus Netter F. Atlas of Human Anatomy. 1989;Plate 202.

Left Atrium, Posterior Wall Variable Anatomy (Common) SVC RAA LAA RSPV LSPV LIPV RIPV IVC Nathan, Circ Res, 1969

Left Atrium, Posterior Wall Pulmonary Vein Isolation Nathan, Circ Res, 1969?

Atrial Fibrillation Ablation Technique Combined Modality Imaging Fluoroscopy and now fluoroless 3-D electroanatomic mapping Intracardiac echo

Left Atrial Mapping and Catheter Ablation Visualization: Intracardiac Ultrasound Tenting of the intra-atrial septum during transeptal catheterization An 8 Fr model also was announced in June 2004 (?release date?) Transeptal Access to LA AcuNav 10 Fr Phased Array Diagnostic Ultrasound Catheter (by Acuson)

New technology:

PV Isolation by RF Lesion Before …

Electronically Isolated PV After …

SUMMARY Atrial Fibrillation Ablation FOR WHOM? (Paroxysmal or Persistent) AF w/ “significant symptoms” associated Refractory to AADs First line thrapy for certain pts HOW? Electrical isolation of pulmonary veins Atrial tissue substrate modification Accomplished via catheter ablation/cryo balloon combined w/ multiple imaging modalities

Actual Afib Ablation Cases

Questions ?

Thank You !