Katheterablatie van atriumfibrilleren Waar staan we? Lukas Dekker

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Katheterablatie van atriumfibrilleren Waar staan we? = Outcome Lukas Dekker

Agenda What are the relevant endpoints? Outcome in paroxysmal, persistent and permanent AFib. Potential determinants of outcome. Longterm follow up. Outcome in structural heart disease. Outcome in various age groups.

Potential endpoints Symptoms. Asymptomatic episodes occur, and probably more often after PVI. ECG monitoring. The more, the lower the success. Long term endpoints. Often only 1 yr follow up. With or without AAD. Often put together. ‘Hard endpoints’. Reduction of stroke and mortality? Health economics. PVI seems cost-effective after 4 y. What are relevant endpoints?

Symptoms will fool you Quirino et al. PACE. 2009;32:91-98 What are relevant endpoints?

Method of monitoring What are relevant endpoints? 1- or 7-day Holter at 0,3,6,12 m. Kottkamp et al. JACC. 2004

Outcome: the surgeon leads the way 95% SR QoL  MAZE for lone AFib Jessurun, Circulation 2000;101: Lönnerholm, Circulation 2000;101: Outcome in paroxysmal, persistent and permanent AFib

Paroxysmal AFib Outcome in paroxysmal, persistent and permanent AFib The A4 study. 1,8 PVI per patient. 24 h Holter at 3,6, 12 m. Endpoint: >3’ AF or symptoms Jais et al. Circulation.2008;118:

Long lasting, persistent AFib Stepwise approach for persistent AFib Hocini et al. JACC. 2010;55: Outcome in paroxysmal, persistent and permanent AFib LA termination. 12 y AFib RA termination. 23 y AFib No termination. 35 y AFib

Permanent AFib Outcome in paroxysmal, persistent and permanent AFib Elayi et al. Heart Rhythm : CPVA= circumferential PV-ablation PVAI = PV-isolation PVAI = PV-isolation + CFAE-ablation

Permanent AFib Outcome in paroxysmal, persistent and permanent AFib

Ultra-structural remodeling Outcome in paroxysmal, persistent and permanent AFib

Fisher JD, et al. PACE 2006;29: Outcome depends on input Outcome in paroxysmal, persistent and permanent AFib

Haïssaguerre’s Approach Potential determinants of outcome Haissaguerre et al. NEJM. 1998;339:

Circumferential ablation Potential determinants of outcome

Segmental or Circumferential ? Karch et al.Circulation 2005 Oral et al. Circulation 2003 Potential determinants of outcome

Size matters Potential determinants of outcome Cappato et al. Circulation.2005;111:

Size really matters Potential determinants of outcome Cappato et al. Circulation.2005;111:

Atrial size matters too N=88 Parikh et al. PACE. 2010;33:

Some patients probably surrender more easily Long term follow up

The future remains full of questions Long term follow up FU 38 m. after PVI for persistent AFib Pratola et al. Circulation. 2008;117:

Do not forget about your patient! Long term follow up AF-free 1 yr after PVI without AAD Shah et al. JCE. 2008;19: Hypertension! Anticoagulation?

PVI in HCM Outcome in structural heart disease =on/off AAD =off AAD Bunch et al. JCE. 2008

PVI in heart failure Outcome in structural heart disease Change in LVEF (n=58) SR in 78% Hsu et al. NEJM. 2004; 351:

PVI in “heart failure” Outcome in structural heart disease Hsu et al. NEJM. 2004; 351:

PVI as first line therapy in the young? Outcome in various age groups 0% complications Leong-Sit et al. Circ A&E.2010;3: N=232N=438 N=570 N=308

AFib is age dependent Outcome in various age groups

PULMONARY VEIN ABLATION VERSUS AMIODARONE IN THE ELDERLY PAVANE Outcome in various age groups

Conclusions PVI has developed into a very efficacious treatment. PVI may be on its way to become first line therapy in selected patients, such as the young. More data on hard endpoints and longterm follow-up are needed.