1. AF ablation is a waste of time and money
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital

2. AF ablation is a waste of time and money: (you must be joking!)
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital

3. A recap of what we’ve learnt this morning….

4. AF kills you (slowly)….

5. AF makes you miserable….

6. 2.4% of the total NHS budget
AF costs megabucks….
2.4% of the total NHS budget

7. Conventional treatments limited efficacy
Drugs only work in 1 in 3 patients

8. Not only are drugs potentially ineffective but…..
They often cause unacceptable side effects
Discontinuation rates due to Adverse Effects:
CTAF: 18% Amio, 11% Sotalol
AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide
They may increase mortality
SPAF: esp. in heart failure
AFFIRM: AAD associated with  mortality (p=0.0005)

9. Dronedarone isn’t the answer….
Mild antiarrhythmic action
AF recurrence at 1 year: 64% vs 75% for Placebo
<< Amiodarone (free from AF at 6 mo: 37% vs 58%)
Increased mortality in Heart Failure (ANDROMEDA)
Only approved by the NICE with reservations

10. ….and neither is cardioversion

11. Finally, a cure is in sight!......
Culprit: triggers in pulmonary veins

12. Treatment: Pulmonary Vein Isolation

13. Current success rates 80%
The procedure works…..
Current success rates 80%

14. in long standing persistent AF too..
Redo
AAD therapy
Results
Complications
Haissaguerre
JCE 2005 60
1/2
Stopped at ablation
95% at 11 months
2 Tamponades
Oral
NEJM 2006 77
1/3
Amio 6/52 pre & 3/12 post
77% at 1 year
Postch
Circ 2008 88
81% at 20 months
1 TIA Lo
JCE 2009 87
1/4
AAD for 2/12 post
79% at 21 months
1 Tamponade

15. It’s clearly better than drug therapy

16. AF ablation has evolved rapidly…
Success rates have doubled
Paroxysmal AF: 40-50% to 80-90%
Persistent AF: 30-40% to 70-80%
Procedure times have halved
From 4-6 hours to 2-3 hours
Complication rates have halved: 4% to 2%

17. Current technology has improved accuracy

18. The last thing we now need is a party pooper!

19. Drugs Ablation 30% efficacy 80% chance of cure Life long suffering
One-stop solution

20. If you always do what you always did…you’ll always get what you’ve always got

21. Yes, AF ablation costs money…
100,000 AF cases a year Median 1.5 procedures
£4000 per ablation
Total cost: half a billion pounds

22. But where would you rather spend this money?
? Iraq War: £ 4.5 billion (Mar 2006)
? Olympics: £9.8 billion
? NHS IT project: £15 billion
? Bank Bailout £850 billion

23. Upfront costs outweighed by subsequent savings…
Costs of recurrent hospital admissions
Electrical cardioversions
Absences from work
Costs of lifelong drug therapy
Regular INR tests
Decreased risk of the serious AF sequalae
Stroke
Heart Failure

24. Measures to make ablation more cost effective
1. Careful patient selection: ablation not offered
Very long standing Persistent AF (>3 years)
Very large LA (>5.5 cm)
Morbid Obesity (BMI >40)
Age >80 years
Significant co-morbidity

25. Measures to make ablation more cost effective
2. Individualised ablation strategy:
Improve single procedure success rates
Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010

26. Finally...
What would you want?!