katheterablatie van atriumfibrilleren waar staan we? lukas dekker
TRANSCRIPT
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?
Method of monitoringWhat 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% SRQoL
MAZE for lone AFibJessurun, Circulation 2000;101:1559-67
Lönnerholm, Circulation 2000;101:2607-11
Outcome in paroxysmal, persistent and permanent AFib
Paroxysmal AFibOutcome 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
Long lasting, persistent AFib
Stepwise approach for persistent AFibHocini 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
Permanent AFibOutcome in paroxysmal, persistent and permanent AFib
Elayi et al. Heart Rhythm. 2008.5:1658-1664
CPVA= circumferential PV-ablationPVAI = PV-isolationPVAI = PV-isolation + CFAE-ablation
Fisher JD, et al. PACE 2006;29:523-537
Outcome depends on input Outcome in paroxysmal, persistent and permanent AFib
Segmental or Circumferential ?
Karch et al.Circulation 2005 Oral et al. Circulation 2003
Potential determinants of outcome
The future remains full of questions Long term follow up
FU 38 m. after PVI for persistent AFibPratola et al. Circulation. 2008;117:136-143
Do not forget about your patient!Long term follow up
AF-free 1 yr after PVI without AADShah et al. JCE. 2008;19:661-667
Hypertension!Anticoagulation?
PVI in heart failureOutcome in structural heart disease
Change in LVEF (n=58)
SR in 78%Hsu et al. NEJM. 2004; 351:2373-2383
PVI as first line therapy in the young?Outcome in various age groups
0% complicationsLeong-Sit et al. Circ A&E.2010;3:452-457
N=232 N=438 N=570 N=308