Samir Rafla- Real life outcome of atrial fibrillation ablation-CardioAlex 2014

1. Real life outcome of atrialReal life outcome of atrial
fibrillation ablationfibrillation ablation
Samir Rafla, FACC, FESC
Professor of Cardiology
Alexandria Univ.

2. 22
Methods and Results-—A structured electronic
database search of the scientific literature was
performed for studies describing outcomes at ≥3 years
after AF ablation, with a mean follow-up of ≥ 24
months after the index procedure. The following data
were extracted: (1) single-procedure success, (2)
multiple-procedure success, and (3) requirement for
repeat procedures. Data were extracted from 19
studies, including 6167 patients undergoing AF
ablation.

3. Single procedure freedom from atrialSingle procedure freedom from atrial
arrhythmia at long-term follow-up wasarrhythmia at long-term follow-up was 53.1%53.1%
(95% CI 46.2% to 60.0%) overall, 54.1% (95% CI(95% CI 46.2% to 60.0%) overall, 54.1% (95% CI
44.4% to 63.4%) in paroxysmal AF, and 41.8%44.4% to 63.4%) in paroxysmal AF, and 41.8%
(95% CI 25.2% to 60.5%) in non paroxysmal AF.(95% CI 25.2% to 60.5%) in non paroxysmal AF.
Substantial heterogeneity (>50%) wasSubstantial heterogeneity (>50%) was
noted for single-procedure outcomes. Withnoted for single-procedure outcomes. With
multiple procedures,multiple procedures, the long-term successthe long-term success
rate was 79.8%rate was 79.8% (95% CI 75.0% to 83.8%)(95% CI 75.0% to 83.8%)
overall, with significant heterogeneity (>50%).Theoverall, with significant heterogeneity (>50%).The
average number of procedures per patient wasaverage number of procedures per patient was
1.51 (95% CI 1.36 to 1.67).1.51 (95% CI 1.36 to 1.67). 33

4. ConclusionsConclusions-—Catheter ablation is-—Catheter ablation is
an effective and durable long-terman effective and durable long-term
therapeutic strategy for some AF patients.therapeutic strategy for some AF patients.
Although significant heterogeneity is seenAlthough significant heterogeneity is seen
with single procedures, long-term freedomwith single procedures, long-term freedom
from atrial arrhythmia can be achieved infrom atrial arrhythmia can be achieved in
some patients, but multiple proceduressome patients, but multiple procedures
may be required.(J Am Heart Assoc.may be required.(J Am Heart Assoc.
2013;2:e0045492013;2:e004549
44

5. Single-Procedure Efficacy of CatheterSingle-Procedure Efficacy of Catheter
Ablation Outcome dataAblation Outcome data
Most studies provided single procedureMost studies provided single procedure
success rates, defined as the percentage ofsuccess rates, defined as the percentage of
patients free of atrial arrhythmia or notpatients free of atrial arrhythmia or not
requiring a second procedure at 12 months.requiring a second procedure at 12 months.
The pooled overall success rate wasThe pooled overall success rate was 64.2%64.2%
(95% CI 57.5% to 70.3%). The pooled 12-month(95% CI 57.5% to 70.3%). The pooled 12-month
success rate for the 11 studies reportingsuccess rate for the 11 studies reporting
outcomes for PAF patients wasoutcomes for PAF patients was 66.6%66.6% (95% CI(95% CI
58.2% to 74.2%), and for the 6 studies58.2% to 74.2%), and for the 6 studies
reporting outcomes for NPAF patients, it wasreporting outcomes for NPAF patients, it was
51.9%51.9% (95% CI 33.8% to 69.5%).(95% CI 33.8% to 69.5%). 55

6. Impact of Multiple ProceduresImpact of Multiple Procedures
Thirteen studies provided outcome dataThirteen studies provided outcome data
taking into consideration the impact oftaking into consideration the impact of
multiple procedures. The overall multiplemultiple procedures. The overall multiple
procedure long-term success rate wasprocedure long-term success rate was 79.8%79.8%
(95% CI 75.0% to 83.8%) in 13 studies (Figure(95% CI 75.0% to 83.8%) in 13 studies (Figure
3). The overall was >50%, indicating3). The overall was >50%, indicating
significant heterogeneity. The multiple-significant heterogeneity. The multiple-
procedure long-term success in PAF wasprocedure long-term success in PAF was
79.0%79.0% in 8 studies (95% CI 67.6% to 87.1%),in 8 studies (95% CI 67.6% to 87.1%),
and that in NPAF wasand that in NPAF was 77.8%77.8% in 4 studiesin 4 studies
(95% CI 68.7% to 84.9%, P=0.9 versus PAF).(95% CI 68.7% to 84.9%, P=0.9 versus PAF).
66

7. Long-term Ablation EfficacyLong-term Ablation Efficacy
Until very recently, few data have beenUntil very recently, few data have been
available on AF ablation outcomes beyond 3available on AF ablation outcomes beyond 3
years after the index procedure. Both single-years after the index procedure. Both single-
and multiple-procedure success ratesand multiple-procedure success rates
showed relative stability at>3 years aftershowed relative stability at>3 years after
index ablation. Including multiple proceduresindex ablation. Including multiple procedures
80% of patients in the included studies were80% of patients in the included studies were
free of atrial arrhythmia at long-term follow-free of atrial arrhythmia at long-term follow-
up.up.
77

8. Table. Complications of CatheterTable. Complications of Catheter
Ablation in the Included StudiesAblation in the Included Studies
88

9. 99

10. 1010

11. 1111
Cryoballoon versus RF Ablation in Paroxysmal
Atrial Fibrillation
J Cardiovasc Electrophysiol. 2014;25(1):1-7
German Ablation Registry-Different Energy Sources in AF
Ablation: Results Acute success rate was similar in both
groups (97.5% in cryo vs 97.6% in RF; P = 0.81).
Procedure times were similar, ablation and fluoroscopy
times were higher in cryoballoon when compared to RF
ablation. Overall complication rate was similar in cryo-
(4.6%) and RF-ablation (4.6%; P = 1.0). Phrenic nerve
palsy was more often in cryo versus RF ablation (2.1%
in cryo vs 0.0% in RF; P < 0.001). Other complications
were more common in RF compared to cryoablation
(4.6% in RF vs 2.7% in cryo; P < 0.05).

12. ConclusionConclusion RF ablation is theRF ablation is the
most widespread ablation method inmost widespread ablation method in
Germany, but use of cryoballoon increasedGermany, but use of cryoballoon increased
significantly. Procedure times were similar,significantly. Procedure times were similar,
but ablation and fluoroscopy times werebut ablation and fluoroscopy times were
longer in cryoballoon ablation. No significantlonger in cryoballoon ablation. No significant
differences were found in terms of acutedifferences were found in terms of acute
success and overall complication rate.success and overall complication rate.
1212

13. Catheter Ablation vs. AntiarrhythmicCatheter Ablation vs. Antiarrhythmic
Drug Treatment of Persistent Atrial FibrillationDrug Treatment of Persistent Atrial Fibrillation
Eur Heart J. 2014;35(8):501-507Eur Heart J. 2014;35(8):501-507
BackgroundBackground Catheter ablation (CA) is a highlyCatheter ablation (CA) is a highly
effective therapy for the treatment of paroxysmaleffective therapy for the treatment of paroxysmal
atrial fibrillation (AF) when compared withatrial fibrillation (AF) when compared with
antiarrhythmic drug therapy (ADT). Noantiarrhythmic drug therapy (ADT). No
randomized studies have compared the tworandomized studies have compared the two
strategies in persistent AF. The presentstrategies in persistent AF. The present
randomized trial aimed to compare therandomized trial aimed to compare the
effectiveness of CA vs. ADT in treating persistenteffectiveness of CA vs. ADT in treating persistent
AF.AF.
1313

14. In total, 146 patients were includedIn total, 146 patients were included
(aged 55 ± 9 years, 77% male). The ADT(aged 55 ± 9 years, 77% male). The ADT
group received class Ic (43.8%) or classgroup received class Ic (43.8%) or class
III drugs (56.3%). In an intention-to-treatIII drugs (56.3%). In an intention-to-treat
analysis, 69 of 98 patients (70.4%) in theanalysis, 69 of 98 patients (70.4%) in the
CA group and 21 of 48 patients (43.7%) inCA group and 21 of 48 patients (43.7%) in
the ADT group were free of the primarythe ADT group were free of the primary
endpoint (endpoint (PP = 0.002), implying an= 0.002), implying an
absolute risk difference of 26.6% (95% CIabsolute risk difference of 26.6% (95% CI
10.0–43.3) in favour of CA.10.0–43.3) in favour of CA.
1414

15. The proportion of patients free ofThe proportion of patients free of
any recurrence (>30 s) was higher in theany recurrence (>30 s) was higher in the
CA group than in the ADT group (60.2 vs.CA group than in the ADT group (60.2 vs.
29.2%;29.2%; PP < 0.001) and cardioversion was< 0.001) and cardioversion was
less frequent (34.7 vs. 50%,less frequent (34.7 vs. 50%,
respectively;respectively; PP = 0.018).= 0.018).
ConclusionConclusion Catheter ablation is superiorCatheter ablation is superior
to medical therapy for the maintenanceto medical therapy for the maintenance
of sinus rhythm in patients withof sinus rhythm in patients with
persistent AF at 12-month follow-up.persistent AF at 12-month follow-up. 1515

16. Pacing or Ablation: Which Is Better forPacing or Ablation: Which Is Better for
Paroxysmal Atrial Fibrillation-RelatedParoxysmal Atrial Fibrillation-Related
Tachycardia-Bradycardia Syndrome?Tachycardia-Bradycardia Syndrome?
Pacing Clin Electrophysiol. 2014;37(4):403-411Pacing Clin Electrophysiol. 2014;37(4):403-411
The outcome of AF ablation in patients with paroxysmalThe outcome of AF ablation in patients with paroxysmal
AF-related tachycardia-bradycardia syndrome wasAF-related tachycardia-bradycardia syndrome was
compared the efficacy of catheter ablation withcompared the efficacy of catheter ablation with
permanent pacing plus antiarrhythmic drugs (AADs).permanent pacing plus antiarrhythmic drugs (AADs).
ConclusionsConclusions:: In patients with paroxysmal AF-relatedIn patients with paroxysmal AF-related
tachycardia-bradycardia syndrome, AF ablation seemstachycardia-bradycardia syndrome, AF ablation seems
to be superior to a strategy of pacing plus AAD.to be superior to a strategy of pacing plus AAD.
Pacemaker implantation can be waived in the majority ofPacemaker implantation can be waived in the majority of
patients after a successful ablation.patients after a successful ablation.
1616

17. Long-term outcome following successful pulmonaryLong-term outcome following successful pulmonary
vein isolation: pattern and prediction of very latevein isolation: pattern and prediction of very late
recurrence.recurrence. J Cardiovasc Electrophysiol.J Cardiovasc Electrophysiol. 2008 Jul;19(7):661-7 2008 Jul;19(7):661-7
RESULTS:RESULTS: During 28 +/- 12 months follow-up, 23 of 264 During 28 +/- 12 months follow-up, 23 of 264
(8.7%) patients had recurrence of AF. The actuarial (8.7%) patients had recurrence of AF. The actuarial
recurrence at 2 years post-ablation was 5.8% and recurrence at 2 years post-ablation was 5.8% and
increased to 25.5% at 5 years. Compared with long-term increased to 25.5% at 5 years. Compared with long-term
responders, more patients with late recurrence had responders, more patients with late recurrence had
hypertension and hyperlipidemia. Among 18 patients hypertension and hyperlipidemia. Among 18 patients
with recurrent AF necessitating repeat PVI, 15 (83%) with recurrent AF necessitating repeat PVI, 15 (83%)
required re-isolation of > 1 PV and 28 of 45 (58%) PVs required re-isolation of > 1 PV and 28 of 45 (58%) PVs
showed reconnection. All PVs were re-isolated and five showed reconnection. All PVs were re-isolated and five
(28%) patients had additional linear ablation. All 15 (28%) patients had additional linear ablation. All 15
patients became AF-free again.patients became AF-free again.
1717

18. Catheter ablation for paroxysmal andCatheter ablation for paroxysmal and
persistent atrial fibrillation.persistent atrial fibrillation.
Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2012 Apr 18;4:CD007101 2012 Apr 18;4:CD007101
Randomised controlled trials (RCTs) A total of 32 RCTs Randomised controlled trials (RCTs) A total of 32 RCTs
(3,560 patients) were included. There were no (3,560 patients) were included. There were no
differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65), differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65),
fatal and non-fatal embolic complication (RR 1.01, 95% fatal and non-fatal embolic complication (RR 1.01, 95%
CI 0.18 to 5.68) or death from thrombo-embolic events CI 0.18 to 5.68) or death from thrombo-embolic events
(RR 3.04, 95% CI 0.13 to 73.43).Comparisons of (RR 3.04, 95% CI 0.13 to 73.43).Comparisons of
different CAs; 25 RCTs compared CA of various kinds. different CAs; 25 RCTs compared CA of various kinds.
Circumferential pulmonary vein ablation was better than Circumferential pulmonary vein ablation was better than
segmental pulmonary vein ablation in improving segmental pulmonary vein ablation in improving
symptoms of AF (p<=0.01) and in reducing the symptoms of AF (p<=0.01) and in reducing the
recurrence of AF (p<0.01). recurrence of AF (p<0.01). 1818

19. Catheter ablation for atrial fibrillationCatheter ablation for atrial fibrillation. . J AmJ Am
Coll CardiolColl Cardiol 2011; 57:160-166.2011; 57:160-166.
Among 100 patients, 175 ablations were performed, with Among 100 patients, 175 ablations were performed, with
a median of two procedures performed per patient. a median of two procedures performed per patient.
When researchers examined recurrences since the last When researchers examined recurrences since the last
ablation, the arrhythmia-free survival rate increased, with ablation, the arrhythmia-free survival rate increased, with
investigators reporting rates of investigators reporting rates of 87%, 81%, and 63% at 87%, 81%, and 63% at
one, two, and five yearsone, two, and five years. Overall, 77 patients were . Overall, 77 patients were
arrhythmia-free at one-year follow-up, and 19 of these arrhythmia-free at one-year follow-up, and 19 of these
patients presented with a later recurrence. The presence patients presented with a later recurrence. The presence
of valvular heart disease and nonischemic dilated of valvular heart disease and nonischemic dilated
cardiomyopathy were independent predictors of cardiomyopathy were independent predictors of
recurrent atrial fibrillation in multivariate analysis.recurrent atrial fibrillation in multivariate analysis.
1919

20. A recent worldwide survey reportedA recent worldwide survey reported 87458745
patients treated at 181 centres.patients treated at 181 centres. The numbers perThe numbers per
year increased from 18 patients in 1995 to 5050year increased from 18 patients in 1995 to 5050
in 2002. The majority underwent segmentalin 2002. The majority underwent segmental
pulmonary vein isolation,pulmonary vein isolation, 27.3%27.3% had more thanhad more than
one procedure, and major complicationsone procedure, and major complications
occurred inoccurred in 6.0%6.0%;; 52%52% became asymptomatic,became asymptomatic,
and a further 23.9% were improved byand a further 23.9% were improved by
antiarrhythmic drugs. Also of note is the fact thatantiarrhythmic drugs. Also of note is the fact that
centres which had performed the mostcentres which had performed the most
procedures tended to have the highest successprocedures tended to have the highest success
rates.rates. Cappato RCappato R, Calkins H, Chen S-A, , Calkins H, Chen S-A, et al.et al. Worldwide survey Worldwide survey
on the methods, efficacy, and safety of catheter ablation for on the methods, efficacy, and safety of catheter ablation for
human atrial fibrillation. Circulation 2005;111:1100–5human atrial fibrillation. Circulation 2005;111:1100–5
2020

21. A non-randomised study examining outcomeA non-randomised study examining outcome
in 589 patients following catheter ablation forin 589 patients following catheter ablation for
AF showed improved mortality, morbidity, andAF showed improved mortality, morbidity, and
quality of life, compared to 582 medicallyquality of life, compared to 582 medically
treated patients. Indeed, the overall survivaltreated patients. Indeed, the overall survival
of ablated patients was no different to that ofof ablated patients was no different to that of
the general population, matched for age andthe general population, matched for age and
sex.sex.
Pappone C, Rosanio S, Augello G,Pappone C, Rosanio S, Augello G, et al.et al. Mortality,Mortality,
morbidity, and quality of life after circumferentialmorbidity, and quality of life after circumferential
pulmonary vein ablation for atrial fibrillation:pulmonary vein ablation for atrial fibrillation:
outcomes from a controlled nonrandomized long-outcomes from a controlled nonrandomized long-
term study. J Am Coll Cardiol 2003;42:185–97term study. J Am Coll Cardiol 2003;42:185–97 2121

22. In-Hospital Complications Associated With CatheterIn-Hospital Complications Associated With Catheter
Ablation of Atrial Fibrillation in the United StatesAblation of Atrial Fibrillation in the United States
Between 2000 and 2010.Between 2000 and 2010. Analysis of 93 801 Procedures. Analysis of 93 801 Procedures.
DeshmukhDeshmukh. Circulation.2013; 128: 2104-2112. Circulation.2013; 128: 2104-2112
The overall frequency of complications wasThe overall frequency of complications was 6.29%6.29%
with combined cardiac complications (with combined cardiac complications (2.54%2.54%) being) being
the most frequent. Cardiac complications werethe most frequent. Cardiac complications were
followed by vascular complications (followed by vascular complications (1.53%1.53%),),
respiratory complications (respiratory complications (1.3%1.3%), and neurological), and neurological
complications (complications (1.02%1.02%). The in-hospital). The in-hospital mortality wasmortality was
0.46%0.46%. Annual operator (<25 procedures) and. Annual operator (<25 procedures) and
hospital volume (<50 procedures) were significantlyhospital volume (<50 procedures) were significantly
associated with adverse outcomes. There was aassociated with adverse outcomes. There was a
small (nonsignificant) rise in overall complicationsmall (nonsignificant) rise in overall complication
rates.rates. 2222

23. Trends inTrends in
ComplicationsComplications
for AFfor AF
AblationsAblations
Deshmukh.Deshmukh.
Circulation.201Circulation.201
3; 128: 2104-3; 128: 2104-
21122112
2323

24. Complications of AF ablation:Complications of AF ablation:
DeathDeath: Death is an infrequent complication of AF: Death is an infrequent complication of AF
catheter ablation. peri-procedural death incidencecatheter ablation. peri-procedural death incidence
observed in catheter ablation of AF does not differobserved in catheter ablation of AF does not differ
from the incidence of peri-procedural death infrom the incidence of peri-procedural death in
catheter ablation of supraventricular tachycardias.catheter ablation of supraventricular tachycardias.
CausesCauses: the need of a transseptal puncture to reach: the need of a transseptal puncture to reach
the left atrium and the PV ostia, the handling andthe left atrium and the PV ostia, the handling and
manipulation of catheters in the left atrium and themanipulation of catheters in the left atrium and the
association of radiofrequency-dependent lesions inassociation of radiofrequency-dependent lesions in
the left atrium with very high levels ofthe left atrium with very high levels of
anticoagulation.anticoagulation.
2424

25. Cardiac tamponadeCardiac tamponade (both acute(both acute
and/or late) has demonstrated to be the mostand/or late) has demonstrated to be the most
common fatal complication leading tocommon fatal complication leading to
cardiac arrest during or after AF cathetercardiac arrest during or after AF catheter
ablation, followed by development of atrio-ablation, followed by development of atrio-
oesophageal fistulas. Ischaemic brain oroesophageal fistulas. Ischaemic brain or
cardiac insults are the third most frequentcardiac insults are the third most frequent
causes of death followed by extrapericardialcauses of death followed by extrapericardial
bleedings related to subclavian or PVbleedings related to subclavian or PV
perforation and by post-operative massiveperforation and by post-operative massive
pneumonia refractory to antibiotics.pneumonia refractory to antibiotics.
2525

26. Atrio-oesophageal fistulaAtrio-oesophageal fistula is a veryis a very
rare complication of AF catheter ablation.rare complication of AF catheter ablation.
this complication is the most dreadful andthis complication is the most dreadful and
lethal among all the others related to AFlethal among all the others related to AF
catheter ablation.catheter ablation.
Haemorrhagic ComplicationsHaemorrhagic Complications
Haemorrhagic complications include majorHaemorrhagic complications include major
and minor bleedings. Cardiac tamponadeand minor bleedings. Cardiac tamponade
has to be considered a major bleeding and ishas to be considered a major bleeding and is
by far the most common major complicationby far the most common major complication
of AF catheter ablation.of AF catheter ablation. 2626

27. Thromboembolic EventsThromboembolic Events
The introduction of open-irrigated cathetersThe introduction of open-irrigated catheters
and the use of early and aggressiveand the use of early and aggressive
heparinization have reduced significantlyheparinization have reduced significantly
the risk of cerebrovascular events relatedthe risk of cerebrovascular events related
to the procedure.to the procedure.
Pulmonary Vein StenosisPulmonary Vein Stenosis: Occurring in 1–: Occurring in 1–
3% of cases.3% of cases.
Phrenic nerve injuryPhrenic nerve injury occurred in 0.48% ofoccurred in 0.48% of
cases.cases.
2727

28. Left atrial tachycardias or left atrial fluttersLeft atrial tachycardias or left atrial flutters
are the most common 'electrophysiological'are the most common 'electrophysiological'
complications of AF catheter ablation.complications of AF catheter ablation.
Occurring in up toOccurring in up to 31%31% of patientsof patients
undergoing this procedure, theseundergoing this procedure, these
arrhythmias are often more symptomaticarrhythmias are often more symptomatic
than AF itself because they are oftenthan AF itself because they are often
associated with high regular ventricularassociated with high regular ventricular
response.response.
2828

29. 2929
Schematic of
common lesion
sets employed
in AF ablation

30. Figure . Strategies for Rhythm Control in Patients withFigure . Strategies for Rhythm Control in Patients with
Paroxysmal and Persistent AFParoxysmal and Persistent AF
3030

31. 3131
*Catheter ablation is only recommended as
first-line therapy for patients with paroxysmal
AF (Class IIa recommendation).
†Drugs are listed alphabetically.
‡Depending on patient preference when
performed in experienced centers.
§Not recommended with severe LVH (wall
thickness >1.5 cm).
║Should be used with caution in patients at
risk for torsades de pointes ventricular
tachycardia.
¶Should be combined with AV nodal blocking
agents.