1. INTERVENTIONAL TREATMENT OF ATRIAL FIBRILLATION St. Mary’s Hospital February – August 2007

2. The Problem

3. 534000 people with AF in the UK in 1995 Direct cost £244 million – 0.62% of NHS expenditure Hospitalisation (50%), drugs (20%) Long term nursing care £46.4million

4. 5 YEARS LATER 534000 people with AF in the UK in 1995 Direct cost £244 million – 0.62% of NHS expenditure Hospitalisation (50%), drugs (20%) Long term nursing care £46.4million Direct cost £459million in 2000, 0.97% of total expenditure Long term nursing are £111 million

5. YEAR 2000

6. DoH guidelines – AF ablation Minimum standards for centres performing AF (both paroxysmal and persistent) ablation are: At least 50 cases should be performed each year and each physician should perform at least 30 cases each Centres performing AF ablation should have surgical cover on site. The success rates (defined as patient symptom free) averaged over 3 years for ablation of AF should be at least 60% off drugs. It is accepted that to achieve these success rates many patients (approximately 50%) will require multiple procedures. The major complication (defined as a complication requiring therapeutic intervention) rates for catheter ablation should be less than 3% overall.

7. St Mary’s – Cardiology 39 6 3 10 n=58, March to August 2007

8. What do we do? Technologyn Conventional22 CARTO10 Artic Front6 Robotic6 Ablation Frontiers3 ESI2 Mesh ablator3

9. Ablation techniques Technologyn Conventional (22)PVI CARTO (10)PVI / WACA Artic Front (6)PVI 6 (NACA) Robotic (6)PVI 4; WACA 2 Ablation Frontiers (3)PVI/CFEA ESI (2)Guided WACA Mesh ablator (3)PVI

10. Absolute Musts Any technology targeting the PV-LA junction (i.e. ALL) must have DOCUMENTATION of the presence or absence of isolation after ablation All linear lesions must be documented to be either blocked or not and must have a delay documented

11. Who to ablate Capacity for 4000 ablations in the UK pa Currently 2-3/week at SMH Likely to increase to 4-5/week Symptomatic Failure of >1 antiarrhythmic drug Informed consent at time of clinic visit –i.e. 3% risk of potentially serious complication –30-50% likelihood of second procedure to achieve success –60-80% success rate for PAF –50-70% for CAF

12. How to ablate Paroxysmal AF –Confirmed PVI by en effective technology Persistent AF –Confirmed PVI by an effective technology –Complete linear lesions –Organisation of “fractionated” potentials Permanent AF –Confirmed PVI by an effective technology –Complete linear lesions –Organisation of “fractionated” potentials

13. How to follow up 3,6,12 month clinical reviews, QoL & ECG Holter at 6 months Anticoagulation Hard end points Holter/memo showing more than 30 seconds of AF/Atrial Flutter or Atrial Tachycardia is considered a failure. ECG showing AF/ Flutter or Atrial Tachycardia. Soft end points Symptoms suggestive of AF QOL score

14. Indication for surgical AF ablation: Consensus statement (1)Symptomatic AF patients undergoing other cardiac surgical procedures (2)Selected asymptomatic AF patients undergoing cardiac surgery in whom the ablation can be performed with minimal risk (3)Stand-alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, have failed one or more attempts at catheter ablation, or are not candidates for catheter ablation.

15. Summary of consensus statement for surgical AF ablation In summary, all patients with AF undergoing other cardiac surgery should be considered for AF ablation if the risk of adding the procedure is low, there is a reasonable chance for success, and the surgery is performed by an experienced surgeon. A LA procedure should consist of PV isolation ideally with a connecting TRANSMURAL lesion to the mitral valve annulus. When it can be safely performed, complete EXCLUSION of the LA appendage should be considered. A biatrial procedure should be considered for (those with symptomatic AF and) those with longstanding persistent AF.

16. Whatever we do, we will still only be scratching the surface…