2. Contemporary Atrial Fibrillation Management
Morhaf Ibrahim, MD. FHRS

3. Nothing to Disclose

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

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

6. Signs and Symptoms Palpitations Weakness Dizziness
Reduced exercise capacity
Dyspnea
Asymptomatic

7. 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!

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

9. 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

10. Diagnostic Testing: EKG

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

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

13. Management
Rate Control
Rhythm Control
Anticoagulation

14. 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)

15. 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

16. Rhythm Control
Indications
Symptoms of a-fib
Personal preference

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

18. 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

19. 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

20. Anticoagulation – Long Term

21. 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

22. Atrial Fibrillation Ablation

25. 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.

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

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

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

29. 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)

30. New technology:

31. PV Isolation by RF Lesion
Before …

32. Electronically Isolated PV
After …

33. 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

34. Actual Afib Ablation Cases

48. Questions ?

49. Thank You !