1. Katheterablatie van atriumfibrilleren Waar staan we? Lukas Dekker

2. Ik sta meestal hier

3. Katheterablatie van atriumfibrilleren Waar staan we? = Outcome Lukas Dekker

4. 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.

5. 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?

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

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

8. Outcome: the surgeon leads the way 95% SR QoL  MAZE for lone AFib Jessurun, Circulation 2000;101:1559-67 Lönnerholm, Circulation 2000;101:2607-11 Outcome in paroxysmal, persistent and permanent AFib

9. 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;118:2498-2505

10. Long lasting, persistent AFib Stepwise approach for persistent AFib Hocini et al. JACC. 2010;55:1007-1016 Outcome in paroxysmal, persistent and permanent AFib LA termination. 12 y AFib RA termination. 23 y AFib No termination. 35 y AFib

11. Permanent AFib Outcome in paroxysmal, persistent and permanent AFib Elayi et al. Heart Rhythm. 2008.5:1658-1664 CPVA= circumferential PV-ablation PVAI = PV-isolation PVAI = PV-isolation + CFAE-ablation

12. Permanent AFib Outcome in paroxysmal, persistent and permanent AFib

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

14. Fisher JD, et al. PACE 2006;29:523-537 Outcome depends on input Outcome in paroxysmal, persistent and permanent AFib

15. Haïssaguerre’s Approach Potential determinants of outcome Haissaguerre et al. NEJM. 1998;339:659-666

16. Circumferential ablation Potential determinants of outcome

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

18. Size matters Potential determinants of outcome Cappato et al. Circulation.2005;111:1100-1105

19. Size really matters Potential determinants of outcome Cappato et al. Circulation.2005;111:1100-1105

20. Atrial size matters too N=88 Parikh et al. PACE. 2010;33:523-540

21. Some patients probably surrender more easily Long term follow up

22. The future remains full of questions Long term follow up FU 38 m. after PVI for persistent AFib Pratola et al. Circulation. 2008;117:136-143

23. Do not forget about your patient! Long term follow up AF-free 1 yr after PVI without AAD Shah et al. JCE. 2008;19:661-667 Hypertension! Anticoagulation?

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

25. PVI in heart failure Outcome in structural heart disease Change in LVEF (n=58) SR in 78% Hsu et al. NEJM. 2004; 351:2373-2383

26. PVI in “heart failure” Outcome in structural heart disease Hsu et al. NEJM. 2004; 351:2373-2383

27. PVI as first line therapy in the young? Outcome in various age groups 0% complications Leong-Sit et al. Circ A&E.2010;3:452-457 N=232N=438 N=570 N=308

28. AFib is age dependent Outcome in various age groups

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

30. 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.